YAK616.21
EBK 58.8
1169
PeKOMCHflOBaHO yHe6HO-MeTOflHHeCKHM oGteflHHCHHCM
no MCflHUHHCKOMy H <J)apMaueBTHHecKOMy o6pa30BaHmo By30B POCCHH B
yne6Horo noco6H« jura CHCXCMH nocJiesyaoBCKoro
npo(J)eccHOHajibHoro
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npo<J)eccop Kacpe,apbi
7
9
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. HayK C. B. Moposoea
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no oropHHOJiapuHrojiorHH: YHe6. noco6ne / M. A. Pbivniia,
A. B. KHCCJICB, B. A. ^ayKHHa, O. B. AnflaMOBa. — HoBOCH6HpcK: Cn6MeflHSflax HFMA, 2005. — 213 c., HJI. — (IHicojia npaKTHHCCKoro Bpana).
ISBN 5-85979-158-5
/laHHoe yieSnoe noco6He aBJiaerca OCHOBHWM MaxepHajioM OJM noaroxoBKH
K npaKXHHecKHM 3aH«rneM no OTopHHOJiapHHrojioraH cxyfleHTOB jieieGHoro, neflHaxpHHecKoro H cxoMaxojiorHHecKoro ({laKyjitxexoB. Iloco6ne noapo6HO HJIJIIOcxpHpoeaHO, coflep*nr coBpeMCHHtie cBe^eHiw HS o6nacxn anaxoMKH, <J>H3HOJioFHH JIOP-opranoB, oco6eHHOCTH KJIHHHKH H Mcxoflw jieneHHH HaH6oxtee pacnpocxpaHeHHtix JIOP-saSoneBaHHH. MaxepHan CHcxeMaxHSHposaH corjiacno yne6HOH
nporpaMMe no OTopHHOJiapHHronorHH B MeflHijHHCKMX sysax, aaanrHpOBan npneuH(J)HKe (JiaKyjibxexos.
YflK 616.21
EEK 58.8
ISBN 5-85979-158-5
© PtiMiiia M. A., KwceJieB A. B.,
HayKHHa B. A., AnaaMOBa O. B.,
2005
© HFMA, 2005
TeMa I. HCTOPHfl POCCHHCKOH OTOPHHOJIAPHHrOJIOrHH.
HPHHIIHnW OBCJIEAOBAHHfl BOJItHOFO B JIOP-KJIHHHKE.
METO^W HCCJIE^OBAHIW JIOP-OPFAHOB
11
I. Hcxopiwi H nyxH passHXHH oxenecxBeHHOH oxopHHOJiapHHrojiorHH
12
II. Mexo,m>i HccjieaoBaHHfl JlOP-opraHOB. SnaKOMCXBo c pa6oxoii
oxoJiapHHroJiorHHecKoro ox^ejienHa 6o^bHHqbi
18
TeMa II. HOC H OKOJIOHOCOBWE HA3yXH
27
I. <5H3HonorHHecKaa poub HOCOBOFO ^wxaHHa
28
II. KnHHHHecKaa anaxoMim noca H npHflaxoHHbix naayx noca
34
TeMa HI. FJIOTKA
46
I. KjiHHHHecKaa anaxoMHa TJIOXKH
47
II. <l>H3HOJionia FJIOXKH. MexoflH HCCJieflosaHiw FJIOXKH
53
TeMa IV. yXO: CJiyXOBOH AHAJIH3ATOP
57
I. KnHHHHecKaa aHaxoMHH cjiyxoBoro anajiHsaxopa
58
II. On3HOJiorHfl cjiyxoBoro ananHaaxopa
68
TeMa V. yXO: BECTHByjIHPHWH AHAJIH3ATOP
79
I. AnaxoMHa nepH<J)epHHecKoro peuenxopa BecxH6ynHpHoro aHajiH3axopa....80
II. 4>H3HOJiorHa Becxn6yjiHpHoro ananHsaxopa. Mexo^bi nccne^oBaHHa
BecxH6yjiapHbix peanuHH
82
TeMa VI. AHATOMO-«DH3HOJIOrHHECKHE OCOBEHHOCTH
FOPTAHH
90
I. KjiHHHHecKaa anaxoMHa ropxaHH
91
II. <!>H3no.riorHfl ropxaHH. Mexoau HccjieflOBaHHH ropxaHH. BBe^CHHe
B (})OHHaipHK)
TeMa VII. 3AEOJIEBAHHfl HOCA H OKOJIOHOCOBWX HA3yX
I. 3a6ojieBaHHfl napyxcHoro noca
97
105
106
Or/lABJIEHME
6
II. 3a6oJieBaHHa neperopo^KH aoca ............................................................... 109
III. BocnajiHxejibHbie saGojiesaHHa nojiocTH Hoca ........................................ 1 12
IV. BocnajiHTenBHwe saSojieBaHHa OKOJIOHOCOBHX nasyx ........................... 125
V. PHHoreHHbie op6HTajibHbie ocjioxcneHHa .................................................. 132
Teiwa VIII. 3ABOJIEBAHHH FJIOTKH. TOH3HJIJIOrEHHbIE
OCJIO2KHEHHH ............................................................................................. 138
Teiwa IX. 3AEOJIEBAHHLH YXA. OTOrEHHBIE BHYTPHHEPEimblE
OCJIO5KHEHHH ......................................................................................................... 154
Teiwa X. 3AEOJIEBAHIW FOPTAHH. OnYXOJIH JIOP-OPFAHOB.... 174
I. BocnajiHxejibHbie 3a6ojieBaHHa ropxaHH .................................................... 175
II. PaccxpoHcxBa HHHepBauHH ropxaHH ......................................................... 180
III. OnyxojiH JIOP-opranoB ........................................................................... 182
Teiwa XL HEOTJIO3KHHE COCTOflHHfl
B OTOPHHOJIAPHHrOJIOrHH ................................................................. 190
I. TpasMH JIOP-opranoB
...............................................................................
191
II. IIoBpexcfleHHa oKOJiOHOCOBbix nasyx ........................................................ 193
III. Ocxpaa HeHpoceHcopnaa xyroyxocxb ...................................................... 194
IV. HHOpoflHtie xejia yxa ............................................................................... 196
V. HHOpo^Hbie xena DOJIOCXH noca H npnaaxoHHtix naayx noca ................. 197
VI. HoCOBblC KpOBOXCHCHHa
..........................................................................
200
VII. Ocxpwe cxenosbi ropxaHH ...................................................................... 204
208
CHHCOK jiHTeparypbi ........................................................................................ 209
OxopHHOJiapHHrojionwecKaa cjry^cSa saHHMaex BSOKHO6 MCCXO B CHCXCMC 3ApaBOOXp3HeHHa, nOCKOJIbKy
o6ecne»iHBaex ^HarnocxKHecKyio H JieneGiryio noMomB
12-15 % oGiqero HHCJia 6ojibHtix. Ha 3a6ojieBaeMocxb
BepxHHX flbixaxejibHwx nyxefi OKasbisaex sHaiHxejibHoe
B^HflHHe KjiHMaxHHecKaa 3ona, 3KOJiorHHecK3H o6cxaHOBKa. B csasH c 3XHM Ha xeppHxopHH Haniefi cxpaHbi
Ha6jiK)flaioxca oxjiHHHa B cxpyicxype oxopHHOJiapHHrojiorHHecKofi 3a6ojieBaeMocxH: B esponeHCKOH
npesajiHpyiOT 6one3HH FJIOXKH (31-43 % cpeaa
CKOFO H cejibCKoro Hacejienna COOXBCXCXBCHHO), na
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6ojie3HH Hoca H OKOJiOHOCOBbix nasyx (16-19%). 3aropxaHH Bcxpenaioxca HanGojiee pe^KO, HO
onyxojieH JIOP-opraHOB 6ojiee 50 % npnxoflHxcfl
na onyxojiH ropxaHH. B CHGnpCKOM pemone HaH6ojiee
ninpOKO pacnpocxpaneHbi 6ojie3HH aepxHHx ^wxaxejibHHX nyxen (40-43 % ox oSmero KOHH^ecxBa oxopHHojiapHHrojioraHecKHx 6ojibHbix): HaHSojibmee KOJIHHCCXBO 6ojibHwx cxpaflaex BOcnajiHxejibHbiMH 3a6oneBaHHaMH FJIOXKH, na BxopoM MecTe — BOcnajiHxejibHbie sa6ojieBaHna noca H npH^axoHHbix naayx noca, 17-20%
6ojibHbix HMCIOX naxojionno yxa. B nocne^HHe ro^bi BOSpocjia rpynna OHKOJioranecKHx 6om>Hbix — JK> 14-16 %
ox o6ujero KOJiHiecxBa.
H coioianbHaa snanHMOCxb oxopHHOJia. B caMOM flene, noxepa cjiyxa, peHH, paBHOBecna, myM B yuiax oxpaacaroxcH na xpyflocnocoSnocxH
ero MopajibHOM cocxoaHHH. PeGenoK, pano nocnyx, oGbinno ne MOXCCX Haynnxtca roBOpnxb
H Bbipacxaex rjxyxoHCMBiM. /le(})eKTbi penn Hapyiuaiox
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8
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CHa, Memaex xpy^oBOH flearejibHOcxH, Hepe^KO ^OBOflHx ao oxnaaHHa.
He 6yflex npeyBenHHeHHCM yxBepxcflarb, HXO 3HaHHH, nojiyneHKbie npn H3yHCHHH oxopHHOiiapHHrojiorHH B Byse, npHroflflXcs B jno6oH oxpacjin npaKXHHeCKOH MeflHIJHHbl, 3. BJiaflCHHC BOnpOCaMH HCOXJIOXCHOH nOMOIUH BX04HX B pafl
npoSneM KJIHHHHCCKOH xepanHH H neanaxpHH.
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xojibKO BonpocH oxopHHOJiapHHrojiorHH, BXOflamHe B yneSHyK) nporpaMMy MCflHiiHHCKoro Bysa, H ne npexenflyex na HCHepnwBaromee HSuoaceHHC BCCX npo6neM coBpeMeHHoH oropHHOJiapHHrojiorHH.
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no,zmep>KKy H noMomb B noflroxoBKe HJiniocxpauHH KHHFH.
OxopHHOJiapHHrojionia — cneuHajibHaa KUHKHHCHcimroiHHa, Haynaiomaa MOp4>OJioro-4>H3HOJiorHOCOOCHHOCXH H naxojiorHio yxa, BepxHHx flwxanyxeii H CMeacHwx c HHMH o6jiacxeii. Ee nanpoHcxoflHX ox rpe^ecKHx CJIOB otos — yxo,
rhinos — HOC, laryngos — ropraHB H logos — ynenHe.
OxopHHOJiapHHrojiorHH — cneuHajibHOCTb yHHKajn>naa. C oanoH cxopoHti, ona CHHraerca «y3Kofl» flHcujmJIHHOH, HO B paMKOX 3TOH «y3KOH» flHCUjmJIHHW CCXb
6ojn>nioe KOJonecrBO HanpaBJieHHH, npnaaiouiHx cneuHajibHOCTH BneiaxjwiomyK) MHororpaHHOcn>. HsHanajibHo
6buiH BbineneHbi otojionw, JiapHHrojiorHa, pHHOJioma,
6poHxonoma. Ilosace nojryHHJiH csoe pasBHrne JIOP-OHKononM, flercKaa oxopHHOJiapHHrojion«i, ajuiepma B oxojiapHHrojiorHH, njiacxHHecofl H peKOHcrpyKXHBHaa XHpypnw jraqa, xapyprna B o6jiacTHTOJIOBHH UICH, OXOHCBpojionw, xHpypraa ocHosaHHa Hepena. OropHHOJiapHHroJioraa paccMaxpHBaer 6oju>myio nacxb aHaimsaxopOB cencopHtrx cHcreM. 3xo, npe»ae Bcero, cjryxoBOH aHajmsaxop, HrpawumH BaxcHemnyio DOJIB B npouecce nosnaHHa,
nocKom>Ky Sjiaroflapa cjiyxosoMy anajiHsaTOpy ^opMHpyexca peneBas fyyaiayifi. B KOMnexeHUHio oxopHHOJiapHHrojioniH Bxoflax xaicace BecxHSyjiapHtiH, ooOHareJitHBiH H
BKycoBOH aHanHsaxopbi. B CJDBHCXOH o6ouoHKe BepxHHx
flbDcaxejn>HbK nyxefi sajioaceHti pa3Hoo6pa3Htie peuenxopbi — Mexano-, 6apo-, xepMO- H xeMOpeuenropti. HopMa^bHaa 4)H3HOJioma JlOP-opraHOB OKasbroaex cymecxBeHHoe BJIHSHHC Ha a^eKBaiHbiH JieroHHbm rasooSMCH,
cxa6HHbHyio reMO/iHHaMHKy, ujipKyjiainco crmHHOMosroBOH JiCHflKOCXH, HXO oSyC^OBJOfflaCX B3aHMOCBfl3b JIOP-Op-
ranoB c fleaxejibHocxbro BCCX CHCXCM opraHHSMa.
IlaxojiorHHecKHe npoueccbi JIOP-opraHOB BKjHonaiox B ce6a BCC BI-WW BOcnaneHHa: 3Kccy^axHBHO-flecrpyK-
10
BBEflEHUE
XHBHOC, pearHHOBoe, rpanyiieMaxosHoe; ^ereHepaxHBHO-aecxpyKXHBHwe npoueccw, onyxojiH, xpaBMaxHHecKHC noBpexyieHna. flpaae xaxoe noBepxnocxHoe 3HaKOMCXBO c oxopHHOJiapHHixmorHeH nosBOJiaex caeJiaxb Bbisofl, HXO oxopHHOnapHHronor flOjmeH 6bixb xopomo snaicoM c HopMajibHOH H naxojiornHeCKOH (j)H3HOJioraeH H aHaxoMHCH, a xaicxe c pas/iejiaMH <J)H3HKH — aicycxHKOH H MexaHHKOH.
OxopHHOJiapHHrojiorafl — cneiHiajibHOCXb xnpyprHHCCKaa, H spaqy neo6xo.ZIHMO xopomo snaxb anaxoMHio yxa H sepxHHX flbixaxejibHbix nyxeii, OCHOBH
o6meH XHpyprHH. Bonbiiioe KOJIHTCCXBO naxojiornnecKHX cocxoflHHH JIOP-opraHOB aBJiaexca CHMOXOMOM o6meH naxojioraH opranHSMa, HXO o6ycjiOBJiHBaex
MCTOPMfl POCCMfiCKOM
OTOPMHOJIAPMHrOJIOrmi.
nPUHMUHbl OBCJlEflOBAHU^
BOJlbHOrO B J1OP-KJ1MHMKE.
METOflbl HCCJlEflOBAHUJl
JlOP-OPfAHOB
6M3 I.
Heo6xOflHMOCTb 3H3HH3 XCpanHH H HCBpOJIOrHH.
B Hanane CBoero pasBHxna oxopHHOJiapHHrojioraa 6wjia B OCHOBHOM xepaneBXHHCCKOH cneuHanbHOCXbio, B nacxoamee BpeMa uinpOKO npHMenaK)xca XHpyprHHecKHe BMemaxenbcxsa — ox rosejiHpHbix onepauHii na yxe no nosofly xyroyxocxH, Becxn6yjiapHOH RHcfyyHKiwui H niyMa B ymax, npoHSBO^HMbix c noMombio onepaqHOHHoro MHKpocKona, ao pacuiHpeHHbix onepauHH na uiee npn
sjioKaqecxBCHHbix HOBoo6p330B3HH3X. IIoaBHJiocb H 6wcxpo pasBHsaexca HOBOC
HanpaBJieHHe — 4>yHKqnoHajibHaa MHKpoxnpyprHa noca H npn^axoHHbix nasyx.
OxopHHOJiapHHrojioraa — flHcuHnjinna B 3H3HHxejibHOH cxeneHH npo<|>HJiaKxHHecKas. Oco6oe BHHMaHHe yflejiaexca flHcnanceproauHH, BKJHOHaromeH B ce6a
aKXHBHoe BbiaBjieHHe H jieneHHe 6ojibHbix, ^HHaMHiecKoe Ha6juoaeHHe sa HHMH,
Mepbi npo<})HJiaKXHHecKoro xapaKxepa.
— 180
LJejib aaHflTMfl. OenafleTb npaicrnMecKHMn
npoBecrvi nepeflHiora pnHocKonnio, aaflHraro pnHOCKonnto,
OTOCKOnmo, MeacxpapuHrocKonnio, HenpnMyio napMHrocKonmo; npnroTOBMXb yujHoii, HOCOBOM saTHMK; npoeec™ n
oueHMTb npo6y aHeMH3aunn; Mccnefloeaib flbixare/ibHyio
dpyHKMMK) Hoca (npo6a c Baroii, flbixarejibHbie nflTHa).
1 . HayHMTbCH opraHMSOBbiBarb pa6onee wecro OTOpMHonapuHronora.
2. OSHaKOMMTbCa C OCHOBHbIMM MHCTpyM6HTaMH flf\
ocMorpa JIOP-opraHOB.
3. O3HaKOMMTbCfl C MHCTpyMeHTa^bHblMM M H6MHCT-
pyweHTanbHbiMM weroflaMM nccneflOBaHUfi JlOP-opraHOB,
HayMMXbCJI
CXewaTMHHO
M3O6pa>KaTb yBMABHHyiO
3HflOCKOnMMeCKyiO KapTMHy.
4. OaHaKOMMTbCfl c opraHM3auneM pa6oTbi JlOP-orfle/ieHMH
GOJIbHMLJlbl.
JJononHumenbHO drm neduampuvecKoao,
cmoMamonoauvecKoso <pai<yfit,memoe:
5. OSHaKOMMTbCJ) C OC066HHOCT51MM o6c/ieflOBaHMB
flereii
B JlOP-miHHMKe.
OcHameHMe. OcseTmejibHbie npn6opbi: MCTOHHMK
cBexa, noftHbivi pecpneicrop, orocKon, napuHrocKon, BOontMKa.
HaSop MHcrp/MeHTOB. HocoBbie sepKa/ia, ujnaienM,
BopoHKM, ropiaHHbie n HocomoroHHbie aepKana,
i HaBHBHbie, nnHqeibi yiuHbie, nnHLierbi HocoBbie.
12
Teivia I. HCTOPMfl POCCMMCKOM OTOPMHOJlAPMHrOJlOrMH...
Pa6oMee MCCTO. MHCTpyMeHxa/ibHbiPi CTOJIMK, HacronbHan Jiaiuna, cnnproBKa, flsa cryna.
Mecro npoBefleHMH saHnrnH. y^eQuaa KOMHaxa, OTflenem/ie
ronorviM.
jiMTeparypa:
1 . Co/idamoe M. B. JleKqun no OTopnHonapMHro/iornM. — M.:
1990.
2. OevuHHUKoe K). M. OTOpuHonapuHronornfl. — M.: MeAnijMHa, 1995.
3. LUanmypoe A. f., LUeepbizun B. B., Mvenudse T. n. Enorpa(pMHecKMM c/ioeapb flejrre/ieM oxenecTBeHHOM oxopMHonapnHronon/in. — MpKyrcK, 1998.
4. LUeepuauH B. B. PyKOBOflcxso no flexcKoii OTOpuHOJiapuHronornn. — M.:
, 1985.
I. MCTOPMfl M nVTM PA3BMTMfl OTEMECTBEHHOM
OTOPMHOJlAPMHrOJlOrMM
OxopHHOJiapHHFOJiorafl — Hayica oxHocnxejibHo MOJioaaa. Haiajio oxopnHOnapHHrojiorHH nojioxceno B cepe^HHe nponijioro cxojiexna xnpypraMH H xepaneBxaMH oSmero npo(J>HJia. B nepsoH nojioBHHe XIX B. MHOFHC pyccKHe npo<J>eccopa, xnpyprH H xepanesxbi yzjejiajiH SHainxejibHoe BHHManHe flHarnocTHKe H
JICHCHHIO 3a6ojieBaHHH yxa, noca, ropjia. npo<J)eccop Me^HKo-xHpyprHHecKOH
aKaflCMHH FT. II. 3a6ojlOUKHH-^eCHXKOBCKHH OflHHM H3 HCpEblX npHMCHHH IiyHK-
UHIO H npOMWBaHHe BepXHC-HejiiocxHOH nasyxH nepes 3y6Hyio antBeojiy H co6aHBK) HMKy. HM ony6jiHKOB3HH KHHFH «O 6oJie3H»x BepxHCHejiiocxHOH nasyxH» H
«O 6one3nax noca H HOCOBMX nojiocxeH». FeHHajibHtiH pyccKHH xHpypr
H. H. IlHporoB, Hepe^KO saxparHBaBuiHH B CBOHX xpyaax Bonpocu JlOP-xpaB-
I. McTopMfl M nyrn
oxeHecTBeHHoti oxopuHonapuHronoruM
13
— HacxnaH, 6bina oxKpbixa B 1 896 r. B r. MOCKBC na cpe^cxBa K). H. Ba33HOBOH, AcficxBOBajia npH MOCKOBCKOM HMnepaxopCKOM YHMBepCHxexe.
OcHOsaxeJieM H pyKOBOflHxejieM nepsoH JIOP-KJIHHHKH B POCCHH, a xaicace
nepsbiM pyccKHM npo(J)eccopOM oxopHHOJiapHHrojiorHH SBJISCXCS H. II. CnMaHOBCKHH. B CBOCH KJIHHHKC OH BnepBbie O&bCflHHHJI OXHaXpHK) H pHHOJiapHHrOJIOFHK),
Koxopue flo 3XOFO ciHxajiHCb pasHbiMH cneqHajibHocxjiMH. IIoflo6Hbie KJTHHHKH B
Espone noxsanHCb XOJH>KO nocjie IlepBOH MHPOBOH BOHHI>I. H. fl. CHManoBCKOMy
npHHaAJieacax nepswe cxaxbH o (^HSHOJIOFKH sepxHHX AtixaxejibHbix nyxeH H HX
B33HMOCBH3H c pa6oxoH cepffna, jicFKHX. 3xH xpyflbi HaiiiJiH CBoe oxpaaccHHe B
onbrrsx HSBecxHoro <J)H3HOJiora H. II. HaBJioBa no HsyHCHHK) 6e3ycnoBHbix pe$JICKCOB c Hcnojn>3OBamieM o6oHaxejibHbix H cjxyxoBbix pasflpaMCHxejiefi.
IIpo(J)eccop MeaHKO-XHpyprHHecKOH aKa^eMHH C. II. BOXKHH — ocHosonoJIOXCHHK oxeiecxBCHHOH HayHHofi KJiHHHHecKOH Mc^nuHHbi — cxpeMHJicH ycxaHOBHXb XCCHyiO CBH3b KJIHHHHeCKOH MCflHUHHbl C aKCnepHMCHXajlbHOH (^HSHOJIO-
rHe8. C 3XOH uejibro C. II. BOXKHH Bnepswe B POCCHH cosaan B 1860-1861 rr.
npn aicafleMHHecKOH xepaneBXHqecKOH KJIHHHKC MeflHKO-xHpypFHHecKOH aKaaeMHH 3KcnepHMeHxajibHyio Jia6opaxopHio, a B 1878 r. npHFJiacnji saseflOBaxb axoft
jiaSopaxopneH H. II. IlaB^OBa, xoraa eme cxyaenxa V Kypca MeflHKo-xnpyprHHCCKOH aKafleMHH. C. II. BoxKHHy npHHa^jieacHX 6ojibiuafl sacnyra B pasBHXHH
OXOpHHOJiapHHFOJIOFHH, X3K K3K OH BCaHCCKH IKXHSepHCHBaJI pa3BHXHC MOJIOflOH
nayKH. YqeKHKOM H. IT. CHMaHOBCKoro aBJiaexca caMbift HSBCCXHWH pyccKHH
pHHOxnpypr B. H. BOX^CK. OH pyKOBOAHJi KJIHHHKOH BoeHHo-MeanuHHCKOH
aKafleMHH c 1918 no 1956 r. Ero xpyaw no KOppeioiHH ae^opMauHH HOCOBOH neperopOAKH caejiajiH ero OCHOBOIIOJIOHCHHKOM cenxoanacxHRH. C 1957 no 1975 r.
JIOP-Ka4>e,npOH BoeHHO-MeaHUHHCKoft aKa^eMHH saaeflOBaji KpynHHH cneunanHCx
B OXHaXpHH H KOCMeXHHCCKOH MBflHUHHe K. Jl. XHJ1OB, KOXOpblH 3aHHMaHCH H3yH6-
MaXOJIOFHH, CnpaBCflUHBO npH3H3H OCHOBOnOJIOaCHHKOM XHpyprHHCCKOH OXOpH-
HH6M 3aiUHXHbIX (JlHSHOJlOrHHCCKHX M6XaHH3MOB CJIH3HCXOH JblXaXCJIbKblX nyXBH,
. H. H. IlHporoBbiM sajioHceHH anaxoMHHecKHe OCHOBM fljia pasoxopHHOJiapHHrojiorHH B POCCHH. B CBOCH KHHre «Tonorpa(J)HHecKaH anaHJiJirocxpHpoBaHHaa paspesaMH, npoBejeHHHMH nepes saMopoaceHHoe xejio nejioBCKa B xpex HanpaBJieHHax» H. H. FlHporoB c 6ojibinoH xoqnocxbK) onncaji anaxoMHio UOJIOCXH noca, ero npHflaxoiHbix nasyx. OH nepsbiii onHcan
semicanalis obliquus, anaxoMHio Hococjiesnoro Kaaajia, KpOBOCHa6aceHHe H HHHepaauHK) npH^axoHKbix nasyx Hoca. Cpe^H ero xpy^oB — cxaxbH o pHHonjia-
nofl ero pyKosoacxBOM 6bui paspaSoxan opHTHHanbHWH cnoco6 xnpyprHHecKoro
jieneHHH oseHbi, 3HflOHa3ajibHbie BMeiiiaxejibcxBa npn onyxojiax rnno^Hsa.
CXHKC, OCXaHOBKC HOCOBOFO KpOBOXeHCHHfl, OOepaXHBHOM JieHCHHH paK3 FaHMO-
pOBOH naayxH.
Cpe^H flpyrnx BUflHbix fleaxejien MC/JHUHHU xoro BPCMCHH B 4>yH.aaMeHX
OXOpHHOJiapHHrOJIOFHH BHCCJIH CBOH BKJiafl K). K. IIlHMaHOBCKHH, H. M. BoJIKO-
BHH, H. <5. Bym, K. cp. YflCH, X. X. CajioMOH.
OxnpaBHOH XOHKOH B P33BHXHH OXOpMHOJiapHHTOJIOrHH B POCCHM MOHCHO CHH-
xaxb oxKpbiiHe Asyx JIOP-KJIHHHK: nepsaa KJiHHHKa 6buia oxKpuxa B 1893 r. B
r. CaKKx-OexepSypre H aBJWJiacb nacxbio BoenHO-MeflHUHHCKOH aKaaeMHH, Bxopaa
IlepBblM pyKOBOflHXejICM JIOP-KJIHHHKH B F. MoCKBC 6bIJI C. <£. (})OH IlIxeHH,
KOxopbiH HanGojiee HSBCCXCH CBOHMH xpyaaMH B o6jiacxH oxnaxpHH H ayziHOJioFHH. C. O. 4>OH IIIxeHHOM 6buiH pa3pa6oxaHbi HFJiw fljia nyHKUHH BepxHeqe^ioCXHOH nasyxH nepes cpeflHHH H HHXCHHH HOCOBHC XO^H, sepKana fljia xnpyprHHeCKHX BMCIIiaxeJIbCXB H KayCXHKH B 334HHX OXACJI3X HOJIOCXH HOC3. DpeCMKHKOM
4>OH IIIxeHHa na nocxy pyKOBo^nxejia nepBOH MOCKOBCKOH JIOP-KJIHHHKH cxaji
H3BecxHbiH pyccKHH XHpypr A. O. HsaHOB. OH HSBCCXCH KaK asxop opHFHHajibHOH onepauHH Ha JiyKOBHue apeMHOH BCHH H MOflH<J)HKauHH onepauHH na OKOJIOHOCOBHX nasyxax.
PaSBHXHC OXOpHHOJiapHHTOJIOFHH B CCCP OflHOSHaHHO OU6HHXb CJ1O3KHO. C Ofl-
HOH cxopoHbi, npHHuraibi coBexcKoro sflpaBOOxpaHCHHfl — 6ecmiaxHocxb H o6meflocxynHOcxb — cosaanH 6asy ana ycneniHoro passHXHa oxopHHOJiapHHrojiorHH.
IIpo4)HJiaKXHHecKaa HanpaBJieHHOcxb coBexcKoro s/jpaBOOxpaHCHHa nojioxooia na-
14
Teiwa I. MCTOPMfl POCCMMCKOM OTOPHHOJIAPMHrOJlorHM...
/uicnaHceproauHH Hacejiemia H 6opb6e c npo<})eccHOHanbHbiMH
MH, HTO naiiiJio oxpaaceHHe B cosaamm npo^HJiaKraraecKoro HanpaBjieHHa oxopHHOjiapHHrojiorHH. ConeraHHe BOSMOJKHOCXH npOBOjHXb naynnbie HCcne^oaaHiw c
npaKTHKOH, 6ecnjiaxHoe Bbicmee MCflHUHHCKoe o6pa3OBaHHe cosflanH yoioBHa ana
noaroxoBKH Gojibinoro KOJinnecxBa KBajiH<}>HUHpoBaHHbix oxopHHOJiapHHrojioroB,
urapoKOMy pacnpocxpaHCHHio JIOP-KJIHHHKH no seen xeppnxopHH POCCHH. C apyroH
cxopoHbi, B 3xox nepHOfl Bca poccHHCKaa HayKa pasBHBanacb HsojiHpoBaHHO ox MHpOBOH HayKH, HCCJICflOBaHHa H flOCXIDKeHHa COBCXCKHX yHCHHX OCXaBaJIHCb HCH3-
BCCXHbiMH H He nojiynajiH ^OCXOHHOH OUCHKH H npH3Haima B MHpe.
B 1922 r. oxopHHOJiapHHroJiorna Gtrria BKjnoieHa B nporpaMMy Kaic oSasaxejn.HbiH npe^Mcx BO BCCX BHCIIIHX MezmuHHCKHx yneGnbix saseaeHHax. ECJIH B qapcKofi
POCCHH cymecxBosano scero jiHuib 5 JIOP-KJiHHHK, xo y»ce B nepabie nocjiepeBOjnouHOHHwe roabi KonmecxBO SXHX KJIHHHK flocxHrjio 60-H, & B Hacxoamee BpeMa B
crpane CBWUIC IOOKJIHHHK oxopHHOJiapHHrojiorHH. B POCCHH cos^aHH H ycnenino
pasBHBaioxca HOBHC oxpacjiH oxopHHOJiapHHrojiorHH: BoenHaa oxopHHOJiapHHrojioma, oxoHeBponoraa, (^OHHaxpna, cyp^ojioma, JIOP-oHKOJioma, flexcKaa OXOPHHOBHAHHX oxopHHOJiapHHrojioroB Bocnnxaji yneHHK H
H. II. CHManoBCKoro npo(j>eccop M. fl>. I^HXOBHH, pyKOBOflHBiiiHH B Capaxose
Ka<J)eapOH oxopHHOJiapHHrojiorHH H nepBHM B cxpane HayHHO-nccjieaoBaxejibCKHM HHCXHXyXOM OXOpHHOJiapHHTOJIOrHH. IllKOJia H. II. CHMaHOBCKOFO 33JIO»CH-
jia OCHOBH npo({)HJiaKXHqecKoro HanpasjieHHa axofi HayKH.
B pasBHxne coBexcKoft oxopHHOJiapHHrojiorHH snaHHiejibHUH Bioiaa BHBC axa4CMHK AMH CCCP H. B. CojwaxoB (r. KyH6binieB). HM, cosMecxHO c P. A. SacocoBHM H H. H. HcaKOBbiM, onHcaH xoHSHjuio-KapanajibHWH pe<})JieKC, no pesyjibxaX3M HCCUCflOBaHHH HHHCpBailHH JIHM^aflCHOHaHOrO rjIOXOHHOPO KOJIblja O60CHOB3-
Hbi HOBbie npeflcxaBJieHHH o ^HSHOJIOFHH H naxojioniH MHHflajiHH, c HX ynexoM
pa3pa6oxana KJiHHHKO-naxoreHexHiecKaa xapaiciepHcxHKa BapnanxoB xeHenna
xpoHHiecKoro xoHSHJuinxa H cofipeMCHHaa KJiaccH<j)HKauHa XOHSHJIJIHXOB. HOMHMO
xoHSHjuiapHOH naxojiorHH B Kpyr HayiHbix HHxepecoB H. E. CojmaxoBa BXO^HJIH:
flHarnocxHKa H jieneHHe nerHOHHbix saGojiesaKHH cpeflnero yxa, naxojiorna BnyxpeHHero yxa, npo<J)eccHOHajibHaa naxojiorHH, JIOP-OHKOJioraa, aexcKaa OXOPHHOa, oprannsanHa JIOP-cjiy»6bi B Mnpnoe H BOCHHOC BpeMa. H. B. CGJInpeanosKena H BHeApena B npaKXHKy Mexo^HKa MeaxoxHMnaHajibHoro
jieKapcxBCHHbix cpe/icxB npH 3a6oJiesaHHax yxa, paspaGoxanw onepaqHH
HHCCKoro flpennpOBaHHa H niynxHpOBaHHa jiaSnpHHxa, ycoseponepauHH na cxpeMCHH, nepsax 6apa6anHOH nojiocxn. H. B. CojmaXOB — asxop H3H6ojiee nonyjiapnoro yne6HHKa ana cxyaenxos MCflHUHHCKHx sy30B «JIeKUHH no oxopHHOJiapHHTOJiorHH», nofl ero pe^aKUHeH Bbinymeno noco6ne
ana Bpaiefi «PyKOBoacxBo no oropHHOJiapHHroJiorHH».
HeoqeHHMaa sacjiyra B passHTHH aexcKOH oxopHHOJiapHHrojiorHH npHHaaneIKWT B. B. IIIespbirHHy (r. MocKBa). HM snepsue B MHpe 6buiH npeflcxaBJieHH pe-
I. McxopHfl M nyrn paaenTMa oxeMecTeeHHOft oxopMHOJiapMHronornn
15
3yJIbXaXbI MHKpOCKOnHHeCKOH JIHarHOCXHKH H MHKpOpHHOXHpypFHH y fleXCH. OH
asjiaexca aaxopoM nepsoro pyKOsoacxBa no .nexcKoK oxopHHOJiapHHrojiorHH, coaaxopOM paaa cnpaBOHHHKOB no oxopHHOJispHHrojiorHH, a xaicace KHHF «Axjiac onepaXHBHOH OXOpHHOJiapHHTOJIOrHH», «KpHOXHpypFHa B OXOpHHOJiapHHTOJIOrHH».
C HMCHCM B. P. Fo(j)MaH3 (r. CaHKX-Hexep6ypr) caasana pa3pa6oxKa HOBOFO
HanpaBJienna B XHpyprHH o6ji3cxn «rojiOBa — inea» — 3HaoH33ajibHaa XHpyprna
rHno(})H3a. Pesyjibxaxw MHorojiexnero xpyaa no xnpyprHH BHCOHHOH KOCXH
o6o6ujeHbi B MOHorp3<J)HH «XHpyprHa JiHueBoro nepBa». Ilofl ero peaaKUHefi H3aan yqe6HHK oxopHHOJiapHHrojiorHH /pia MCflHUHHCKHX sysos.
IIojiyHHJi MHpoBoe npH3H3HHe pa3pa6oxaHHbiH T. H. MapKOBbiM H B. C. KosJIOBHM (r. .flpocJiaBJib) Mexoa JienenHa BocnsjienHa npHaaxoHHbix n33yx noca c
noMombio CHHyc-Kaxexepa ^MHK.
ffflu pasBHxna nporpeccHBHbix xexnojioniH flnarHocxHKH H jieneHHa 336ojieB3HHH JIOP-opraHOB, fljia HnxerpauHH aocxHaceHHH POCCHHCKHX ynenbix B Mnposyio
nayKy B nameS cxpane co3aanbi Haymo-npaicxHtiecKHe o6mecxBa «BcepoccHHCKoe
o6ujecxBO oxopHHOJiapHHroJioroB», «O6mecxBO PHHOJIOTOBW. IlonyjiapH33UHH
oxopHHOJispHHrojiorHH B HauieH cxpane cnoco6cxByrox npo<J)eccHOHajibHbie »cypHajibi: «BCCXHHK oxopHHOJiapHHrojiorHH)), «^ypHaji yniHbix, HOCOBHX H ropjiosbix
6ojie3HeH», «BCCXHHK oxopHHOJiapHHrojiorHH H jioronaxojiorHH», «PHHOJiorHa».
PaaBMTue oTopiiHO/iapiiHronorMii B Cn6iipii
B 1928 r. B r. TOMCKB npHKaaoM napKOMa sapaBOOxpaneHHa H. A. CeMauiKO
6bIJI OpraHH30B3H HHCXHiyX flJM yCOBepIUCHCXBOBaHHa Bpaieft, «npH3B3HHbIH 06-
yayibi SApaBOOXpaneHHa ne xoJibKO CnGHpCKoro Kpaa, HO H npnjieHCMy o6jiacxeH H SBXOHOMHHX pecny6jiHK». Hepes roa nocne
B r. TOMCKC 6bijia opraHHSOBans nepsaa B CnGnpn KnHHHKa
yxa, ropjia H noca. OpraHHsaxopOM H nepBHM pyKOBOflHxejieM KJIHHHKH cxaji npo4>eccop A. H. SHMHH. C ero HMeneM csasano cxaHOBJieHne oxopHHOJiapHHrojiorHH
B TOMCKC, HoBOCHGnpCKC, HoBOKysneuKe. A. H. SHMHH — xnpypr o6nieH npaKxnKH, cxoaji H y HCXOKOB anecxesHOJiorHH. B 1907 r. HM Sbuia samnmena aoKxopcKaa
flHccepxauna no XBMC «K yneHHio o BJinaHHH HapKOsa 34)HpOM H xjiopo^opMOM Ha
6aKxepHU,naHocxb Kposn H 4>arouHxoB». A. H. SHMHH 6bui SeccMennbiM npeaceaaxejieM oSmecxsa oxopHHOJiapHHrojioroB flo 1934 r., opraHnsaxopOM oGiuecxsa noneneHHa rjiyxoncMbix, aKXHBHHM yHacxHHKOM no cosbisy H opraHHsaqHH I H II
BcecH6npcKHX cbesaoB spaieH. B nacxoamee BpeMa Ka^eapon oxopHHOJiapHHroJIOFHH ToMCKoro MeflHqHHCKoro yHHBepcHxexa saBBflyex npo4>eccop A. B. Cxapoxa. B jieneGHOH H HccjieaoBaxenbCKOH pa6oxe Ka<J>eapa aKTHBHO ncnojibsyex snaoCKonHHecKyio <J)yHKiiHOHajibHyK) pHHOxnpyprHio, BoccxaHOBHxejibHyro xHpyprHio
c HcnojibsoBaHHCM MaxepnajiOB c naMaxbro $opMbi.
PasBHXHe oxopHHOJiapHHrojiorHH B HoBOKysneiiKe CBasano c HMCHCM npo<|>eccopa A. H. 3HMHH3 H oxKpbixneM B 1951 r. TocyaapcxBeHHoro HHCXHxyxa fljia
16
TeMa I. MCTOPHfl POCCMI/ICKOI/I OTOPHHOJlAPHHrO/lOn/IM...
M nyrn
ycoBepmcHCXBOBaHHa BpaieS (TUffVE), Koxopbia 6bui nepeBe^en B r. HoBOKyaHCUK (r. CxajiHHCK) H3 HoBOCH6npCKa. BosFJiaBHJi paooxy HHCXHxyxa A. ft. HeSoxapes. Ero nayHHbie pa6oxbi nocBameHbi JIOP-xpasMe, cjiyxonporesHpoBaHmo, HCHpojxHHaMmecKHM HapymeroMM cjiyxa, rojioca, o6oiMHHa, JIOP-omccuiorHH. A. SL HeGoHbiM CnGnpH H /Jajibnero BocxoKa. C 1970 r. Ka^e^py BosrjiaBHJia B. A. QIOKOHnaa. CpeflH paapaSaxbmaeMbix Haynnbix XCM OCHOBHOC BHHMaHHe yuejiaexca BOCCXaHOBHXCJIbHOH XHpypFHH, ayZlHOJIOFHH, OHKOJIOrHH, pHHOHCBpOJIOrHH.
C 1981 r. B HoBOKyanemce oxKpbrra enHHCXBCHHaa B CnQapn Ka<t>e,zq5a jjexcKOH
oxopHHOJiapHHrojiOFHH rHflVBa. BoarjiaBJiaex pa6oxy Ka4>eapbi npo4>eccop K. 3. BopncoBa. CoxpyznfflKH Ka<J>eflpH npOBOJiar caMoe coBpeMCHHoe HccjieflosaHHe cjiyxa
y flcxeii, nofl6op cjiyxosbix annapaxoa, peKOHCxpyKXHBHbie onepauHH na yxe, paapa6axbiBaiox H Bneapaiox B npaKxracy HOBHC cnoco6bi XHMnaHOimacxHKH npH aaSoJieBanHax cpe^Hero yxa. TaioKe Kadpeppa npoBo;0rr oGmne H xeMaxiraecKHe L(HKjiw ycoBepmcHcxBOBaHHa BpaneH-oxopHHOJiapHHrojioroB B pasaene aexcKOH oxopHHOnapHHrojiorHH. HayHHwe HccjieflosaHHa Btmojiiwioxca no xeinaM «AKxyajibHbie Bonpocbi naxoreneaa, flHarHOcxraai H jieneHHH peqHflHBHpjTomero H xpoHmeCKoro moHHoro cpe^Hero oxHxa», «CouHajibHO-nirHeHHHecKne acneicrbi pacnpocxpaHCHHOcxH JIOP-naxojiomH cpe^H aexefi KpynHoro npOMbimneHHoro upmpa
3anaflHOH CnGnpH H opraHHsaura JieHe6HO-npo(J)HJiaKXHHecKOH noMouiH».
PasBHxne oxopHHOJiapHHrojionmecKOH noMomn B r. OMCK& CBasano c pa6oXOH Ka^eapbi OMCKOFO Me^HUHHCKoro HHCxnxyxa. B xeneHne MHOFHX Jiex Ka4>eflpoH saBeAOBaji npo^eccop H. B. MnineHbRHH. Ero pa6oxw nocsameHbi npoGjieinaw onxHMH3aqHH yHeSnoro npoqecca B oxopHHOJiapHHrojiomH, opranHaaUHH noBbimeHiw KBajiH(J)HKauHH JIOP-BpaieH, pasanxHio cypflOJioraiecKOH no-
o6pa3OBaH3 B BOCHHblH SBaKOFOCnHXaJIb. B BOCHHbie FOflbl H HOCJieBOCHHOe BpeMa BO3HHKJI3 H6o6xOflHMOCXb B npOBeflCHHH 6oJIbUIOFO KOJIHHeCXBa HJiaCXHHC-
CKHX onepaiiHH na JIHUC, HXO nocnyacHJio HOHCKOM HOBHX pemeHHH B BoccxanoBHxejibHOH xnpyprHH JIOP-opranoB. C. A. IIpocKypaKOB paspaGoxan H BHC^PHJI
B npaKXHKy Mexoa cnnpajibHoro KOHCHOFO jiocKyxa B KanecxBe xpancnjianxaxa,
coKpaxHXb CPOKH HajieHeHHa 6ojibHwx nocjie njiacxHiecKHX oneB 1,5 pasa. 3xox MCXOA npHnec eMy Mnposyio naBecxHocxb. C. A. ITpoCKypaKOB — asxop csbiuie 100 naynnbix pa6ox, B XOM HHCJIC HasecxKbix MOHOrpa4>HH «BoccxanoBHxejibHbie onepaunn noca, ropna, yxa» H «Onbix pa6oxbi no
BoccxaHOBHxejibHoB xHpyprHH jiHua H JIOP-opraHOB». HayHHo-HccjieflOBaxejibCKoe HanpaBJieHHe Ka4)eflpu B oSjiacxn njiacxHHCCKOH xnpyprHH JiHiia, ocxeonnacxHiecKHx onepauHH npnaaxonHbix nasyx noca coxpanajiocb no 1986 r.
B 1989 r. pyKOBOflHxeJieM KJIHHHKH cxajia yneHHua C. A. HpocKypaKOBa —
M. A. PbiMuia. Ilofl ee pyKOBOJjcxBOM Haynnoe HanpaBJienne Ka^eapw BRjuonaex
B ce6a HayneHHe XPOHHHCCKHX HecneuHiJfHiecKHx nponeccoB sepxHHx
xejibHbix nyxefi H yxa. B paMKax 3xoro HanpaBJieHna ao nacxoamero
npoflOJDKaioxca HccjiejoBaHHa no peKOHCxpyKXHBHO-BoccxaHOBHxejibHOH xnpyp-
MOUIH HaCeJICHHK), CXaHOB^eHHK) H paSBHXHK) SaKpblXOH <J)yHIOlHOHaJIbHO-peKOHCTpyKXHBHOH XHpypFHH B OXHaXpHH, yjIbXpaSByKOBOH OCXCOnjiaCXH^eCKOH
xnpyprHH H JiaaepnoH xepannn B pHHOxHpyprHH. Flofl ero pyKOBOflcxsoM paspa6oxan HOBbiH cnoco6 neieHHa 3a6oneBaHHH TJIOXKH HHSKonacxoxHbiM yjibxpaasyKOM. B nacxoamee BpeMa Ka^eflpofi sase^yex yneHHK H. B. MnmenbicHHa —
npo4)eccop K). A. Kpoxoa. ^ajibHCHmee ycoBepuiencxBOBaHHe MCflHUHHCKOH
yjibxpasByKOBQH annapaxypw H paspa6oxKa HOBOH XBXHHKH npoaojracaexca <J)HpMOH «MexpoMe,a», BosraaBjiaeMoft KanflHflaxoM xex. nayK B. B. IleaflepoM: ycoBepuieHCXBOBaH annapax «ToH3HJinop», cos^an H ycneiuno Bneapaexca pjix neHCHHa xyroyxocxH annapax «AyflHOxoH».
HMCHCM Bbiaaiomeroca aeaxena COBCXCKOH nayKH — A. T. IJIaHxypoBa. OCHOBHOC nanpasjieHHe ero HaynnoH aeaxejibnocxH — JTOP-omcojionia, opraHHsanna
JIOP-cjiy»c6bi, HOBaxopcxBO B oxojiapHHrojiorHH. A. F. IlIaHxypOB — aacjryxcenHbiH H3o6pexaxejib PCOCP, Bbi^aiomwHca opraHHsaxop — noa ero pyicoBOflcxBOM B r. HpKyxcKe npoBefleHO 13 Kpynnbix nayHHO-npaKXHHecKHX
peraonajibHoro, MexcoSjiacxnoro, pecny6jiHKancKoro H coiO3Horo
17
A. F. IlIaHxypOB HMeex 6ojiee 200 aaxopcKHX CBH^exeubcXB Ha rooSpexemia H
yziocxoBepeHHH na pauHOHajiHsaxopcKHe npe/xnoHceHHa.
B 1931 r. rH,ZjyB HS r. ToMCKa 6bm nepesefleH B HoBOcnGnpcK, Kyzia nepeexanH npocjjeccop A. H. SHMHH H ero ynenHK C. A. npocKypaKOB. DepBaa KJIHHHKa B r. HoBocn6HpcKe 6biJia paaBepnyxa Ha 40 KOCK Ha 6aae I-H KJMHHHecKOH
6oJibHHUbi. KnHHHHecKHH Kopnyc HaxoflHJica B 7 KM ox ropojxa npn oxcyxcxBHH
KaKoro-JinSo xpancnopxa. CxaHOBJieHHe KJIHHHKH npoxoflHjio B xaxcejiwx ycnoBnax: cxpoHxeJibHbie fle<J>eKXbi, oxcyxcxBHe BOflbi, npoGneMbi c oxonjieHHCM.
B nepBbie roflbi BpaieH-KypcaHXOB 6bmo Majio, H yneSnaa pa6oxa npOBOflHJiacb
na Romy y npenoAaBaxejieH. IIpO(J)eccop A. H. SHMHH HHxan JICKUHH B HOMepe
FOCXHHHUH, accHCxenx C. A. OpocKypflKOB — Ha KBapxnpe.
C oxKpbixHCM B 1935 r. HoBocn6HpCKoro Me^HUHHCKoro HHCXHxyxa C. A. IIpoCKypaKOB BosrjiaBHJi Ka4>e^py JIOP-GonesneH HMH. flo 1941 r. coxpyzuiHKH Ka(noMHMO yHe6HOH paSoxbi co cxyaenxaMH) cosaaBaji
Maxepnaji ffjin npaKXHHecKHx sanaxHii H jieKUHOHHoro Kypca,
6ojibiuyK> paSoxy B noMomb opranaM sflpasooxpaHeHHa, paaaepHyjiH
pa6oxy cpean Bpaiefl ropoaa. B roaw BOHHBI KJiHHHKa JIOP-6ojieaHeH 6bina npe-
XapCB BHCC GoJIblllOH BKJiafl B OpraHH3aUHK) nOMOIUH JIOP-OHKOJIOFHHCCKHM (X>JIb-
CxaHOBJICHHC H paSBHXHC OXOpHHOJiapHHIXWlOrHH B HpKyXCKC CBasaHO C
OTenecTBeHHOM OTOpMHOJiapuHronornn
FHH, H3yieHHe HMMyHOJIOrHHCCKOH peaKXHBHOCXH 60JIbHHX XpOHHHeCKHMH 33-
V
6ojieB3HHaMH JIOP-opranoB, paapaGaxnaaioxca HOBHC Mexoflbi jieneHHH aaGojieB3HHH JIOP-opranoB, 6ojibuioe BHHMaHHe yaejwexca ncnojibsOBaHHio npnpoflHHX 4>aKxopOB CHSnpcKoro perHona. M. A. PbiMiua o6ocHOBana noJiOHcnxejibHbiB 3<})(J)eKX paflOHOxepannH y GojibHbix c HeHpoceHCOpHOH xyroyxocxbio H KOXjieoBecxH6yjiapHOH flHC^yHKUHen H BHejipHJia B np3KXHKy peaGnjinxsuHio 6ojibHHX c HeftpoceHcopHOH xyroyxocxbio H3 MBCXHUX Kypopxsx c paaoHOBHMH BO-
~^"^:rr^~l
rov BHG Hnvry
18
II. Mexoflbi MccnefloeaHun flOP-opraHoe...
19
Teiwa I. MCTOPHfl POCCHI/ICKOM OTOPMHOJlAPHHrOJlOrHH...
, reorpa<J)HHecKHH, najiex). HK.KBOT: (MarKHH, HajiHine naxonoraiecKHX
CHMnxoMOB), rpaHHUbi neneHH, cejieseHKH. <t>H3HOJion«ecKHe oxnpaBJieHHa 3a
nocneflHHe flse neflenH.
II. METOflbl MCCJlEflOBAHMfl JIOP-OPPAHOB.
3HAKOMCTBO C PABOTOM
oTOJiAPMHronornMECKoro OTAEJIEHMJI
JIoKajibHbiii craryc:
O6cne^oBaHne 6ojibHoro B KJIHHHKC JIOP-6ojie3Heii cjieayex oGmenpHHaxtiM
B MCflHUHHe npHHUHnaM: 1) qejiocxHoe BocnpHaxne 6oJibHoro; 2) HcnojibsoBaHHe
Cy6teKXHBHblX H o6tCKXHBHbIX MCXOflOB oScjICflOBaHHa.
2Kajio6bi OojibHoro Ha MOMCHT ocMorpa: co cxoponu JIOP-opranoB, co
cxopoHH flpyrHX opranoB H CHCTCM opranHSMa.
AHaMH63 3a6oJI6BaHHH:
— flaxa noaBJieHHa »ano6.
- ^HH3MHKa »ajlo6 C MOMCHXa HX HOaBJlCHHa.
— IIpHMeHaeMbie-sa apeMa SOJICSHH Mexoflbi H cpe^cxsa JieneHHa.
— 3<j>4>eKTHBHOcxb npHMeHeHHoro neneHHa.
ripn xpOHHiecKHx BOcnajjHxejibHbix 3a6ojieBaHnax JIOP-opraHOB o6paxnxb
BHHMaHHe Ha flaxy nocneanero oGocxpeHHa, o6myio flJMxejibHOCXb
HHa, na qacxoxy o6ocxpeHHH 3a6ojieBaHH» sa nocjie^HHH FOA
onepaxHBHOe neHCHHe, yxoHHHXb ocoGeHHOcxH flHcnaHcepnoro Ha6jiioaeHHa
6ojibHoro.
— XpoHHHecKHe 3a6oneBaHHa, oco6o
06 HMMyHOfle4)HUHTe (qacxbie npocxyflHbie
saSojieBaHHa flwxaxejibHbix nyxen, ocjioxcHCHHoe xeneHHe BocnajiHxenbHbix 3a6oneBaHHH, rHOHHHHKOBbie 3a6oneBaHHa KOHCH).
— HacjieflcxBCHHOCTb (nopOKH pasBHXHa H flpyraa naxojiorna JIOP-opraHos
y pOflCXBCHKHKOB).
3a6o:ieBaHHa H naxcjiorna GepeMCHHOCXH, npHBOflamHe K
JIOP-opranoB (CH^HJIHC, xy6epKyjie3, BHyrpHMaxoHHaa HH$CKa, npHMCHCHHe B nepHoa 6epeMCHHocxH npenapaTos, o6;iaAaiomHX xepaxorCHHWM flCHCXBHCM).
— IlepeHeceHHbie HH<j>eKU.HOHHwe
c OCJIO*HC-
HHHMH CO CXOpOHbl JIOP-OpraHOB.
— ripo<})eccHa.
H JieKapcxBCHHaa ajuieprHa.
Ofimee cocronHHe 6ojibHoro. OqeHMXb cxenenb xaacecxn cocxoaHHa 6onbHoro, BbiacHHXb, HBM o6ycjioBJieHa xaacecxb cocxoaHna:
CosHaHHe (acHoe, cxenenb yxpaxbi cosnaHHa). IlojioMceHHe 6ojn.Horo (BHHJTKflCHHoe, aicrHBHoe). TeMnepaxypa xejia. Hacxoxa cep^enHbix coKpameHHH B MHHyry,
apxepnaJibHoe aaBJieHHe. JIbixaHHe (cBo6ojHoe, HHcnHpaxopnaa cwbiuiKa, 3KcnnpaxopHaa oflwuiKa), qacxoxaflbixaxeJibHbixflBH5KCHHHB MHHyxy, aycKyjibxauna.
K03KHbIH HOKpOB H CJIH3HCXtie (UBCX, BJI3)KHOCXb, HaJIHHHC BblCbinaHHH). >l3bIK
OCMOTP ofijiacTH «r<uioBa — UICH»: B HejuocxHO-jiHUCBOH, acxexHHecKOH
xHpyprHH npaBHUbHocxb cxpoeHHa itHua npHHaxo onpeaejiaxb B COOXBCXCXBHH co
cxanflapTaMH Jleonapao fla BHHHH. B COOXBCXCXBHH c HHMH npaBHUbno C(j)opMHposaHHoe JIHUO qeJiOBCKa aejinxca na 3 paBHwe B BepxHKajibHOM HanpaajieHKH
nacxn: 1) Bepxnaa xpexb — ox JIHHHH BOJIOC ^o nepenocHiibi, 2) cpeanaa — ox
nepenocHUbi p,o BCPIUHHW Hocory6noro yraa, 3) HHacnaa — ox BepiiiHHbi HOCOrySHoro yraa ao JIHHHH noa6opoflKa. OxKJioneHHa ox yicasaHHbix cxaHaapxoB flaJICKO HC Bcer^a oxnocaxca K GOJICSHH HJIH ypoAcxaaM, HO noflpasyMesaiox OXKJIOH6HHa OX «KJiacCHHeCKOH KapXHHH» BO BHyXpeHHCM CXpOCHHH nOJlOCXCH JIOP-Op-
ranoB. HeoGxoflHMO ynnxbisaxb H pacoBbie ocoSeHHOCxH cxpoeHHa Jinua. HanpHMep, c ynexoM HauHOHanbHocxH H SXHHHCCKHX ocoGeHHOCxeft Bbmejuuox nexwpe xnna Hapyacnoro Hoca: 1) BOCXOHHHH XHH, xapaKxepHbin min napoflOB
ASHH; 2) KaBKascKHH xnn — nenxopHHHHecKHH; 3) HerpoHflHwii xnn — ruiaxHpHHHqecKHH; 4) eBponeHCKHH ran, B KoxopoM pasjiHHaiox xpH ocnoBHbie (J)opMbi:
npaMaa, Bbinyioio-CBOflHaxaa (BbicoKaa H ysKaa cnHHKa noca), BorHyxo-yrjiyGjieHHaa
(mnpOKaa H HHSKaa cnnHKa noca). O BOSMOKHWX anaxoMKHecKHX oxioiOHeHHax
BHyxpeHHero cxpoenna JIOP-opraHOB rosopax CXHTMM ,zBO3M6pHoreHe3a — npnsHaKH BHyxpHyxpo6Horo Hapymemia pasanxna coe^HHHxeiibHOH xKaHH. K xaKHM npn3HaKaM oxHocarca HHSKaa rpamma pocxa BOJIOC, npHpociuaa MOHKH yxa, nniepxejijiopnsM raas, roxHHCCKoe He6o, nmepxejuiopHSM MOJIOHHWX wejies H x. A. 3xn npn3HaKH flocxaxoHHO ninpoKO BCxpenaioTCa H HC Hacxojn>KO rpyGbi, nxoGbi cnnxaxbca
nopoKaMH pasBHxna, HO CCJIH npH ocMOxpe HX HacnnxbiBaexca 6ojibiue naxn, xo HMCerca oienb 6ojibniaa sepoaxHOCXb sHaHHrejibHbix HHAHBH^yanbHbix ocoGeHHocxeH
BO BHyxpCHHeM cxpoeHHH opraHH3Ma. Co cxopoHbi JIOP-opraHOB HaH6ojiee qacxo
scxpenaioxcx OXKJIOHCHHH: mnoreHesHa nasyx noca, KOpoxKaa ysneiKa asbiKa, BepxHefi H HHacHeii iy6bi, HepaBHOMepHbifi o5bCM HOJiocxH Hoca ciipasa H cjiesa, ysocxb
HOCOBtix xoflOB, flHTHCueHUHa KOcxHbix CXCHOK nojiocxeft yxa.
OpH OCMOXpe H6O6xOAHMO o6paXHXb BHHMaHHC Ha CHMMeXpHHHOCXb JIHUa H
men B canrrrajibHOH HJIOCKOCXH, nocKOjn>Ky yBeJiHHCHHe jiHM^axHHecKH
BOcnajnrrejibHbiH OXCK Hepe^KO Menarox HapyacHHH Konxyp. CocxoaHne BCK,
BffiKHocxb raasHbix aSjioK HOSBOJIHX HdauoHnxb BOcnanHxejibHyio BHyxpHrnasHHHHyio naxojiorHK), Koxopaa, icaic npaBHJio, HOCHX pHHorenHHH xapaxxep. IlpH ouemce
KOHCHoro noiqxjBa onHCbroaiox usex KOJKH, Hajinqne BblCbinaHHH, son rnnepeMHH,
noaKOjKHbie reMaxoMbi, Haimnne noBpeameHHH KoacHoro noKpoaa, xapanxep panbi.
rtpn najibnauHH ofijiacrH «rojioea — men» onpeaejiaiox HaJTHnne son 60: ynacxKOB KOMCHOH rHnepxepMHH, ranoxepMHH; naJibHHpyiox XOHKH
xpOHHHHHoro Hcpsa. Ilpn BbcnajieHHH npHflaxoHHbix nasyx noca nepeaKO onpe^ejiaexca HX 6ojie3HCHHOcxb.
20
TeMa I. MCTOPMF) POCCm/ICKOI/IOTOPMHO/lAPMHrOJIOrHH...
n3jibnau,Ha HapyacHoro noca — onpeaejieHne 6one3HeHHOCTH,
naxojiorHHecKOH noflBHMCHOCTH, KpenHxain™.
OGaaaxeiibHO npoBoanxca najibnauna jiHM<})axmecKHX ysjioa: OKOJioyiiiHbix, 33xbuioHHtix, noflqenrocxHbix, nepe^ne- H saflHeuieHHtix, Ha#- H noflicrnoHHHHbix, oueHHB3CXCa paSMCp JIHMCpaXHHeCKHX ySJIOB, nOZUJIDKHOCXb, GoJieSHCHHOCXb, CnaaHHOCXb
c ortpyHcaiomnMH xKanaMH. BosHHicaiomHe BOcnajiHxeJibHbie HSMCHCHHa B mmfya-mHCCKHX yanax, KaK np3BHJio, Hocax BxopHHHbrii xapaKxep. YHHXbiBaa, HXO OTTOK jraM(J)bi
ox oprana ocymecrBJiaexca B onpefleneHHbix HanpasjieHHax, K onpeaejieHHbiM mmfyaXHHCCKHM yjnaM, Bbmejiaiox pemoHapHbie jiHM(|)oy3Jibi (1-ro, 2-ro nopa^Ka) ,nna icaxcfloro oprana.
OpraHHsauHH paGonero Mecra: HncxpyMeHxajibHUH CXOJIHK naxoflnxca
cnpaBa ox 6ojibHoro. HCXOHHHK ocBemeHHa xaioice naxo^Hxca cnpaaa ox GojibHOro, na ypoBHe rjiaa nauneHTa. Ha BepxHefi HOJIOHKB cxojiHKa pacnojiaraiox HHCxbifi HHCTpyMenxapHH, na HHacHefl noJiOHKe — HcnojibsOBanHbiH. Bo BpeMa ocMOXpS Bp3H AOJIHCCH H3flCXb pCSHHOBbie nepH3XKH, M3CKy, 33IUHXHbie OHKH.
Hccjie^oBaHHe JIOP-opranoB:
Hoc. riocne ocMoxps H naubnauHH Hapyxcnoro Hoca, oGnacxH npnflsxoHHbix
naayx noca npHcxynaioT K ocMoxpy npe/WBepna HOJIOCXH noca. ftps ocMOTpa KOXCH
npeansepHa noca 6oJibiiiHM najibiieM npaBOH pyKH npnnoAHHMaiox KOHHHK noca
6oJibHoro. B HopMe npeAasepHe noca CBo6oano ox KOpoqeK, Koaca pososaa, BOJIOcaHbie jiyKOBHLtbi cnoKOHHH. MexoflHKa ocMoxpa HOJIOCXH Hoca cnepeflH Hasbmaexca nepeaneH PHHOCKOHHCH. /(jia ee nposeflCHHa Heo6xo^HMO HOCOBOC sepKano.
IlepeaHHH pHHocKonHa — HOCoBoe sepKajio B JICBOH pyne, npasaa pyna naxoflHxca na xeMCHHOH o6jiacxn 6ojibHoro. KopoxKHe GpanuiH sepnana BBO^ax B
HOJIOCXH noca na 0,5 CM H pasBOflax B Koco-BepxHKajibHOM nanpaB: napyacnaa Gpanma aepKana — B sepxHCM yray npeOTBepna Hoca, BHyxSpaHina — y ocHosaHHa HOCOBOH neperopoaKH. OcMOxp IIOJIOCXH noca
B flByx nosHUHax: ana ocMoxpa HH^CHHX H nacxHHHO nepeannx oxflejioB
nojiocxH Hoca — npH npaMOM norojiOBbi, ana ocMoxpa
H BCpXHHX 0X^61108 - fO-
Puc. 1. HepeflHaH
1 — CpCflHaa HOCOBM paKOBHHa, 2 —
HOCOBOH \OH, 3 — HH)KHaa HOCOBM paKOBHHa,
4
HHiKHHH HOCOBOH XO3, 5
HOCOBOS
neperopoflKa, 6 — o6mnfl HOCOBOH XOA
sanpoKHHyxa nasaa. 06pasonojiocxH noca, BHflHMbie npn
PHHOCKOHHH, yicasaHbi Ha
PHC. 1. B HopMe cjmsHCxaa Hoca
pososaa, uBex oflHHaKOB c UBCXOM
KpacHoS xaHMbi ry6. IIpocBex
o6iuero HOCOBOPO xoaa na ypoBHe
nepe^KHX KOHUOB HHXCHHX HOCOBbix paKOBHH cocxaBJiaex np«Mepno 0,5 CM. HocoBbie xoaH
CBo6oflHbi. IleperopoflKa noca pac-
II. Meroflbi MccneflOBaHun JlOP-opraHOB...
21
no cpeflHeft JIHHHH HJIH onncbiBaioxcfl HCKpHBJieHHa, awpocxbi HOCOBOH neperopo^KH. Heo6xoAHMO ynecxb, HXO HCKpHBJieHne HOCOBOH neperopoaKH, HC conpOBoayjaromeeca napyuieHHeM HOCOBOFO abixanna, He asuaexca
naxojiorneH.
flna neduampuuecKoeo $>avyjibmema. V HOBOpoxmeHKbix nepeflHioio pHHOCKOnHK) npOBOflaX C nOMOIUblO yiHHOH BOpOHKH. npOXOflHMOCXb XOaH OUCHHBa-
K)x c noMoiubto 3OHflHpoBaHHfl nojiocxH Hoca MarKHM KaxexepOM. B Hacxoamee
speMa ana ocMoxpa HOJIOCXH noca y ^exefi, XOHHOH xonHnecKOH flHarnocxHKH saSojieBaHHH HOJIOCXH noca H npHflaxoHHbix nasyx ncnojibsyiox 3H/(ocKonHHecKyK)
MHKpOpHHOCKOnHKD (CM. pHC. 1 IIpHJIO»CeHHa).
OJHHM HS Be^ymHx cHMnTOMOB naxojiorHH nojiocxH Hoca aBJiaerca saxpy^HeHHe HOCOBOro flbixaHHa. OuenHXb cxeneHb napyiueHHa HOCOBOTO awxaHHa
(cnpasa, cueaa) MOHCHO no OXKJIOHCHHK) Ha Bfloxe-Bbifloxe no^HeceHHoro nooneK npaBOH H JICBOH Hos^pe KycoHKa saxbi. BjiaxcHocxb H xeMnepaxypa BHBosayxa npeBbiniarox cooxsexcxByiomHe noKasaxenH oKpyacaromen
na 3XOM OCHOB3HO HCCJie^OBaHHe HOCOBOro abixaHHa no 3anoxeB3HHio
Mex3JMHHecKOH nnacxHHKH Tjiaxuejia — «Mexoa ^bixaxenbHbix naxen». Ilpw neoGxoflHMOCXH 6ojiee XOHHOH OUCHKH HOCOBOTO abixanna nposoflax pHHOMexpHK),
npH Koxopoii rpa<f>HHecKH oxoSpa^caexca CKOpocxb BosayuiHofl cxpyn B HOJIOCXH
Hoca H HOCOBOC conpoxHBjieHHe na B^oxe H Bbifloxe /pa KaayjoH HOJIOBHHH noca.
ITpHHHHaMH HapyniCHHa HOCOBOFO ^bixanHa Moryx 6bixb nmepxpotjiHa HOCOBHX P3KOBHH, HCKpHSJICHHC HOCOBOH neperOpOflKH, afleHOH^bl, nOJIHttbl nOJIOCXH
Hoca, HHopoflHbie xejia. ECJIH HMeexca rHnepxpo<J)Ha HHMCHHX HOCOBHX
xo npH nepeflHCH pHnocKonnH o63op HOJIOCXH noca saxpyflneH H3-33
Horo nepeflHero Kontja HH»HeH HOCOBOH paKOBHHbi. HxoGw ox^H(J)(J)epeHiiHpoaaxb HcxHHHyio rHnepxpo(J)HK» HOCOBUX paKOBHH ox JIOWHOH rHnepxpo<J)HH —
oxeica, npOBOflax npoSy c a-a/ipeHOMHMexHKaMH (npo6a aneMH33UHH CJIHSHCXOH):
na cjiHSHcxyro HOCOBMX paKOBHH HSHOCSX cocyaocyacHBaiomHH npenapax (a^peH3JIHH, H3(J)XH3HH, C3HOpHH, KCHM6JIHH H flp.). IIpH HCXHHHOH FHnepXpO(})HH oSl-
CM HOCOBHX paKOBHH npaKXHHecKH He MCHaexca, HocoBoe flbixanne yjiynniaexca
He3HaHHxe;ibHO HJIH ne HSMenaexca. IlpH JIOJKHOH rnnepxpo^HH HOCOBOC awxaHHC 3HaHHxejibHO ynyHuiaexca, oGteM HOCOBHX paKOBHH yMCHbiuaexca.
C naxojiorneH Hocosorofli>ix3HHaxecno CBassno HSMeneHHe rojiocs — PHHOJI3JIHH. Bbmejiaiox 3aicpbixyio rHycaBOCXb — noasjieHHe Hocosoro oxxeHKa
npn npOH3HomeHHH xojibKO coraacHbix. CocxoaHHe xapaKxepno, Kor^a
cxpye HMeexca MexaHHnecKoe npenaxcxBHe — npn nojinnax HOJIOCXH noca,
HOHflax, ocxpoM pHHHxe H flpyroH naxojiorHH. OxKpbixsa rayc3BOCXb
HOCOBOro oxxemca npn npoHSHonieHHH BCCX ssyKOB — xapaicxepna ana nopaaceHHa
nepBHOH CHCTCMbi: npH flexcKOM uepeGpajibHOM napajiHne, napesax Maraoro ne6a,
npn HCKoxopux nopoicax passHXHa nejiiocxHo-JiHueBOH o6;i3CXH.
B HOJIOCXH Hoca pacnojiaraexca nepniJiepHHecKHH peuenxop o6oHaxenbHoro
anajiHsaxopa. HapymeHwa o6onaHHa Moryx BO3HHKaxb npn nopaxceHHH nen-
22
TeMa I. HCTOPH5R POCCHI/ICKOt/l OTOPUHOJlAPMHrOJlOrMM...
23
II. Mexoflbi MCcnefloeaHMfl JlOP-opraHOB...
xpanbHoro ox^ejia o6oHaxenbHoro anajiHsaxopa (nepuenxHBHaa rano- HJIH anocMHa) H npn napyuieHHH aocxyna Bosayxa B o6oHaxejibHyio o6jiacxb — pHHorennaa rano- HJIH anocMHa. flna HccjieflOBaHH* o6oHaxejibHOH (J)yHKUHM Hoca HCnojibsyiox nexbipe cxan^apxHtix pacxBopa naxynnx semecxB B nopa/jKe ysejiHHeHHa CHJibi sanaxoB cooxBexcxBCHHO HexbipeM rpaflannaM noHHHceHna o6oHaHHa:
I cxeneHb — 0,5 % pacxsop yKcycHOH KHCJIOXH (cjia6biH sanax), II cxeneHb —
HHCXWH BHHHWH cimpx (cpeflHHH sanax), III cxeneHb — HacxoHKa BajiepnaHbi
(cHJibHHH 3anax), IV cxenenb — pacxBOp aMMHaKa (yjibxpacHjibHbiH sanax).
B nojiocxH Hoca H npHflaxonntix nasyxax Hoca o6pa3yexca B cyxKH OKOJIO
500 MJI CJIHSH, Koxopaa nocxoaHno SBaKynpyexca B nocorjioTKy, H MW sxoro ne
saMenacM, CCJIH ne napymeHa xpancnopxHaa (j)yHKU.Ha snHxejiHS. JJjix ouenKH
HHcxaa. OcMoxp Bepxnero oxaejia TJIOXKH — 3HH<J)apHHrocKonHa — nposo^Hxca
c noMombio HocorjioxoHHoro sepKajia (N°N° 0-3) H mnaxejia.
3XOH <J)yHKUHH HCHOJIbSyeXCH CaxapHHOBblH XeCX. B He60JIbIUOM KOJIHHCCXBe C3-
sepxHHH, cpeflHHH, HH»HHH HocoBbie xoflbi. B CBOfle HOCorjioxKH pacnojiaraexca
rjioxoHHaa MHHflajiHHa, na GOKOEMX cxenxax HOCOFJIOXKH na yposne sa^Hero
xapHH Hanocax na cjiH3HcxyK) BepXHe-MeflHanbHbix noBepxHOCxen HHHCHHX H
cpeflHHX HOCOBWX paKOBHH (0,5 CM KsaflH ox nepeflHero KOHqa) H npoxKBOJiexcaHacxb HOCOBOH neperopOflKH. JleByio H npaByro noJiOBHHy noca HCCJieayrox
. OGcjie^yeMOMy npe^jiaraiox cnaHana saaepxcaxb awxanHe, a saxeM
nepes HOC H pox H HC CMopicaxbca. BpeMa noasjieHHa cjiaflKoro BKyca BO
pxy (J>HKCHpyiox ceKynflOMepoM. CpeAHee apema noasjieHHa cjia^Koro BKyca BO
pxy — 12-15 MHHJTT. TpancnopxHyio 4>yHKUHio xaKXce MOXCHO oqennxb c HOMO-
C nOMOUlbK) 3XOH MCXOaHKH MO5KHO OCMOXpeXb H SaflHHC OXflCJIbl HOJIOCXH
Hoca, B cBflSH c qe\ onpasaaHo Bxopoe HassaHHe — sa^Haa pHHocKonna. YCJIOBHa npOBCAeHHa sa/ineH pHHOCKonHH: SSHK Haxo/jHxca B HOJIOCXH pxa, BO BpeMa
HCCJieaOBaHHH GojIbHOH flblUIHX paBHOMBpHO HOCOM H pXOM, 663 3aflep*KH flbIX3-
HHa. TexHHKa HcnojiHCHHa: noaorpexb sepKajio na cnnpxoBKe, ox^aanxb uinaxeJICM asHK KHH3y H Knepe^H, sepKajitHOH nosepxHocxbio ssepx BBCCXH HocornoxoiHoe sepKajio sa He6Hyio sanasecKy, ne Kacaacb HeGnux ayjKCK, «3HKa, saflHen
CXCHKH FJIOXKH. CxCMaXKHCCKH SH^OCKOnHHCCKaa KapXHHa OXpa5KCHa H3 pHC. 3.
IlpH SaflHCH PHHOCKOHHH BHflHbl 3aflHH6 KOHUbl BCCX HOCOBblX paKOBHH,
KOHUa HHXCHHX HOCOBblX paKOBHH
TJIOXOHHbie OXBCpCXKH CJiyXOBblX Xpy6,
xpy6nbie MHHflaJiHHH.
OCMOXP HHKHero ox^cjia FJIOXKH — rHnocjmpHHrocKonHH — npOBoanxca c
noMombio ropxaHHoro sepKajia (N°N° 4-6), caji<J)exKH AJia y^epacaHHa aswKa.
ocMaxpHBaexca ropxanb. Bxopoe HasaaHHe sxoro Mexo^a HCCJIC— nenpaMaa jiapHHrocKonna. YcJiOBHa npOBeaeHHa nccjieflOBaHHa:
IUbK) MeXHJieHOBOH CHHH, JTOJIbHOH HblJIH.
6ojIbHOH BblBOflHX 83HK H3 OOJIOCXH pX3 MaKCHM3JIbHO BHepCfl H BHH3; flbIX3HHe
KoJiHiecxBCHHO oueHHXb npoxoflHMocxb nojiocxH Hoca nosBOJiaex PHHOMCXPH«. Ilpn SXOM Hepes o^Hy Hosflpio H3MepHK)x conpoxHBjieHHe BOSflyoiHoro noxoKa, Hepes apyryio — onpeaejiaiox CKopocxb Bos/iyiiJHoro noxoKa c noMomjbio
HHCBMOxaxoMexpa.
K flonojiHHxeJibHbiM MexojaM HCCJie^OBaHHa oxnocax peHxreHojiorHHecKyro
flHarnocxHRy: oGsopHbie peHxrenorpaMMH npnflaxoHHbix nasyx noca, KOMnbioxepnyK) xoMorpa(j)Hio, MarHHXHo-pesoHaHCHyio xoMorpa<j)HK).
FJIOTKE. OcMoxp cpeanero oxaeJia TJIOTKH (HJIH sesa) — MC3O(J)apHHrocKOnHfl — npoBOflHxca c noMomtio mnaxejia. Illnaxejib naxoanxca B JICBOH pyKe,
6ojibiuoH najieu cnnsy, ocxajibHbie — caepxy. SCB orpannqeH cnnsy KOpneM aswKa H
pacnojioHceHHOH na HCM SSUHHOH MHHflaJIHHOH, cBepxy — saHasecKOH Maraoro ne6a
cnoKOHHoe, paBHOMepnoe, 6es saaepacKH. TexHHKa HcnoJineHHa: ropxaHnoe sepKajio noaorpexb na crmpxoBKe, sepKajio BBoanxca B nojiocxb pxa sepKaJibHon nosepxHocxbio BHHS, HM oxoflBHraexca He6naa sanaBecKa roa^H AO saflHeii CXCHKH
TJIOXKH, HC Kacaacb ne6Hbix ayxceK, a3HKa. Rna ^exajibnoro ocMOxpa rpyuieBHaHHX CHHycoB npocax HccjieayeMoro
cnexb 3ByK «H», npn SXOM rpynieBHflHbie
nojiHOCxbio pacKpHBaroxca.
peAHHH ox^eji raoxKH ocMOxpexb
jierKO, a /ma ocMoxpa Bepxnero H
CXCHKOH TJIOXKH. B HOpMe cjiHsncxaa sesa
pOSOBaa, HHCXaa. He6Hbie MHHflaJIHHBI 0603pHMbI, HO HC saKpblBaiOX 33JIHHe He6Hbie
HOCOrJIOTKH, X03HH H 6oKOBbIC CXCHKH
ITo 6oK3M nepe^HHe H sa^HHe ne6Hbie
ay»cKH orpaHHHHBarox MHnaajiHKOBbie HHIIIH, B Koxopwx pacnojiaraioxca HeGnbie
MHH^ajIHHbl. Csa^H 3CB OIpaHHICH 3aflHCH
Puc. 2. Me3o4>apHHrocKonn«:
3
4 — He6na» MMwanHHa
Oc-
aexcKOM Bospacxe, nosxoMy y aexen npnMenaiox najibqesoe HccjiefloaaHHe HOCOFJIOXKH. MexoflHKa HccjieAOBaHHa: Bpai
Haxo^Hxca csa^n H cnp3B3 ox cnflamero
6ojibHoro. YKasaxejibHbiM najibqcM JICBOH
pyKH <|)HKCHpyexca Jiesaa meKa
3y63MH 6ojibHoro. YKasaxejibHW
npasoH pyKH BBo^Hxca B nocorjioxKy H
KOHHHKOM najibqa omynbisaioxca csoa
(PHC. 2).
1 — CBo6oaHHH Kpafi nepeflHefi He6noH
ay»KH,2 — sa^Hsa HC6HM fly^xa,
rO 3X3HC3 HCoGxOflHM H3BbIK.
MOXp 3XHX OXflCJIOB FJ1OXKH SaXpyflHCH B
«j
-«
c
r
,
FJIOXKH (pHC. 4).
PU
Puc. 3.
1 — rjiotoHHaa MnnaajiHHa,
2 — xoaiiu, 3 —raoTOHHOeOTBepCTHe cjiyxo-
BOH rpydbi, 4 — Mareoe He6o,
5
SaflHHe KOHUbl HOCOBUX paKOBHH
24
Tewa I. MCTOPMfl POCCHI/ICKOI/IOTOPMHOnAPHHrOJIOrnH...
FopxaHb ocMaxpHBaiox c noMombio
3epK3Jia COBMCCXHO C HHHCHHM 3Xa>KOM
FJIOTKH. MexoflHKa Hassana nenpaMOH
jiapHHrocKonHCH, xaK KBK MM BH^HM oxpaaceHHe ropxann B sepKane, H, nanpnMCp, BHflHMHH C33flH HaflFOpxaHHHK H3
caMOM aejie Haxo^nxca Bnepean.
PeajibHyro SHflOJiapHHreajibHyio KapxHHy MOMCHO ysHflexb npn npaMOH JiapHHrocKOHHH, fljin Hero HcnoJibsyexca
ropxaHHHH mnaxejib TnxoMHpOBa, RKPuc. 4. najibueaoe HCcjieflosaHHe
peKxocKon YmpHua, KJIHHKH fljia nnxyHOCOFJIOTKH
6au,HH xpaxen. FIpaMyio jiapHHrocKonnio
Hcnojibsyiox npH Heo6xo;iHMOcxH OCMOXpa ropxaHH y flexen paHnero Bospacxa. TexHHKa npoBCflCHHa npaMOH jiapHHrocKonHH: 6ojibHOH JIOKHX na cnnne, noa HJICHH noflKJiaflbisaexca BaJiHK, rojiosa
sanpoKHHyxa, niea Bbixanyxa. Bpan naxoflnxca y rorojiosba Sojibnoro. KJIHHOK
cxporo no cpeaneH JIHHHH, npH noaBjieHHH Ha^ropxaHHHKa KJIHHOK sasa Hero no ropxaHHOH noBepxnocxH H oxxarHsaiox nasepx. fljisi ocMoxpa
KOMnccypu naflaBJiHBaiox na mnxoBH^HbiH xpani. HenpaMaa JiapHHroCKOHHa npOBOflHxca B flByx 4>a3ax: Ha Bfloxe H npH 4>OHaiXHH. CxeMaxHHCCKH HCnpaMaa jiapHHrocKonna npeflcxaBJiena na pnc. 5. Bxofl B ropxanb orpaHHHHBaex
CBo6oflHbiH Kpan JienecxKa HaflropxaHHHKa. B BecxnSyjiapHOM ox^ejie ropxaHH
jioacHbie rojiocoBbie cmiajiKH, B cpe/ineM OXACJIC — HCXHHHHC rojiocosbie
, nepe^naa KOMHccypa. OonaiiHa
3ByKOB «H» H «3») HO-
SBOJiaex oueHHXb noflBHKHocxb rojiocoBHX CKJia^oK. HH»HHH oxaeji ropxaHH B
HopMe He npocMaxpHBaexca. B npocsexe
rojiocoBOH UICJIH MOWHO yBHflexb nepBbie
Kojibua xpaxeH.
B nocjieflHee BpeMa see ninpe HCnojibsyrox MHKpojiapHHrocKonHio, HS apyrax MexoflOB HCCjieaoBaHHa npHMenarox
peHxreHorpa(J)HK), cxpo6ocKonHK), nneBMorpa(J)Hio.
Yxo. OcMOxp napyacHoro cjiyxosoro
npoxoaa, 6apa6aHHOH nepenoHKH nasbiBaexca oxocKonneH (pnc. 6).
FtpeflBapHxejibHO ocMaxpHBaexca H
najibnHpyexca OKOJioymnaa o6jiacxb, yiuHaa paKOBHna. ^na ocMoxpa
II. Meroflbi HccneflOBahMfl JlOP-opraHoe...
25
Hcnojibsyexca yiunaa sopOHKa FapxMana. KanecxBO ocMoxpa sHannxejibHO
noBbimaexca npn HcnoJibsoBaHHH yseJIHWHXejIbHOH BOpOHKH 3Hrjia, OXOCKO-
na. ^Jjia yjiyniueHHa oSsopa npHMCHaiox OHHCXKy HapyacHOro cjryxoBoro
npoxo^a ox cepnbix Mace yuinbiM
saxHHKOM. IIpaBHJia npoBe^eHHa oxoCKonHH: y sspocjibix — OTranyxb
yiiiHyio paKOBHHy KsaflH H KBepxy, y
aexen — Ksa^H H KHHsy, yKasaxenbHblM H 6oJIbIJJHM naJIbqCM BOpOHKa
Puc. 6. OTOCKOIHM:
1 — 3aaHxa CKjraaKa, 2 — nepejmsa CKJia^Ka,
B HapyacHbiH cJiyxoBOH
3
pyKOHTKa MOJIOTOHKa, 4
KOpOTKHH
^0 ero KOCXHOH nacxn. Hpn
OTpOCTOK MOJIOTOHKa, 5 — CB6TOBOH KOHyc
ocMoxpe oqeHHBaexca uinpHHa npoCBexa napyxcHoro cjiyxoBoro npoxojja cnpaaa H cjiesa, cocxoaHHe KOHCH cjiyxoBOFO npoxoaa, 6apa6aHHaa nepenoHKa. Ilpn HCKyccxseHHOM ocBemeHHH 6apa6annaa nepenoHKa nepJiaMyxpoao-ceporo usexa, B HaxanyxoH lacxn 6apa6aHHOH
nepenoHKH onpe^ejiaexca nynoK, pyKoaxKa MOJioxoiKa, CBCXOBOH Konyc. B HenaxaHyxoH nacxH — KOPOXKHH oxpocxoK MOJioxoHKa. ffflu BbinojineHHa MaHHnyjiaUHH na 6apa6aHHOH nepenoHKe ycJiOBHO ee aejiax na nexwpe nacxn — KBaapanxbi. KBa^paHXH o6pa3yioxca npn nepeceneHKH aByx JIHHHH: npaMOH JIHHHH nepes
pyKoaxKy MOJioxoHKa H nepnenKHKyjiapHOH eii npaMOH JIHHHH, npOBeaeHHOH nepes nynoK. Bbiflejiarox: nepeflHe-HHMCHHH, nepe^He-BepXHHH, sa^He-HH>KHHH H
saflHe-BepxHHH KBaapaHxw (pnc. 7). CBCXOBOH Konyc scema Haxoanxca B nepeaHe-HH^cHCM KBaflpanxe. Hccjie^OBaHHe cjiyxosoro anajiHsaxopa B 6ojibiiieH Mepe
CBasano c oGieKXHBHbiMH Mexo^aMH, xaKHMH KaK penxreH-flHarHOCXHKa, ayflHOMexpna, XHMnaHOMexpHa, HMneflaHCOMexpna, nocKOJIbKy cpe^Hee H BHyxpeHHce
yxo — 3x0 CHCxeMa nojiocxen, pacnojio>KeHHWX B BHCO1HOH KOCXH H HC^OCXynHblX ffflX
Puc. 5. HenpaMaa jiapHHrocKonHa:
1 — jienecTOK HanropraHHHKa, 2 — nepetfHH» KOMHccypa, 3 — jiroKHtie rojiocoBHe
cKJiaaKH, 4 — HCTHHHbie rojiocoBbie cicnaaKH, 5 — qepnajioBHOTWH xpam, 6 — qepna, 7 — Bxoa B nn, 8 — rpyuieBnaHHH CHHyc
Puc. 7. KBa^paHTH 6apa6aHHOH
nepenoHKH:
1 — nepeAHe-BepXHHH KBaapanT,
2 — nepe/jHe-HH>KHHH KBaapanT,
3 — 3ajjHe-HnacHHH KBaapaHT,
4 — 3aaHe-BepXHnfi KeaapaHT
HenocpeflcxBCHHoro oGsopa.
V flexefi paHHero sospacxa npn njiane 6apa6aHHaa nepenoHKa 6bicxpo Kpacneex, noOCMOXP Aexeii nepBoro roaa »CH3HH
x, He napymaa COH peSeHKa.
K ocoGeHHOcxaM HCCJieflosaHHa JIOP-opraHOB y flexefi oxnocHxca xaioce oco6biH nopa^OK ocMoxpa. ECJIH HMeroxca >Kajio6bi, xo
6oJibHOH opran ocMaxpHBaiox nocnejiHHM.
IlpH npOBeaeHHH npo(j)HnaKXHHecKoro ocMoxpa Hcnojibsyexca cjieayroniaa
xejibHOCXb MexoflHK: oxocKonna,
26
Ter/ia I. HCTOPHfl POCCHI/ICKOI/I
PHHOCKOOHH, M63O(j)apHHrocKonHfl, saunas pHHOCKonHfl, nenpsMafl (npn Heo6xoflHMOCXH — npHMax) napHHrocKonHH. HxoSbi HsGexcaxb HeraxHBHoii peaKUHH pe6eHKa na ocMoxp, cjie^yex HHCxpyMCHxapHH na CXOJIHKC ;iep>Kaxb HaicpbixbiM ne, a BO speMH ocMOXpa pasroBapHBaxb H oxsjieicaxb BHHMaHHe peGenica.
Bonpocbi MTorosoro KOHXporm SHHHMM no yewe I
1. riepeHMCJlMTe OCHOBHbie MHCXpyMGHTbl, H606xOflMMbie fl/lfl OCMOX-
pa 6oxibHoro B JIOP-KJiMHUKe.
2. KaK npaBkinbHO opraHMsoBarb pa6oMee wecxo oxopMHonapHHronora?
3. O6-bacHMxe xepMMH «pnHonaJina».
4. KaKMe onosHasaxenbHbie nyHKTbi SapaSanHOM nepenoHKM BW
snaexe?
5. flnfl Mero ncnonbsyexcsi npo6a aHeMMsaunn?
6. FloHeMy npn nposefleHHM HenpHMoii napuHrocKonnn oionapMHronor npocuT 6ojibHoro cnexb ssyKM «n», <o»?
7. Onmukixe xexHMKy nposefleHun nepeflHefi pnHocKonnn.
8. Onuiiinxe xexnuKy nposeaeHMJi saflneti pnHOCKonnn.
9. Onniunxe xexnnKy npoBeflenmi wesodpapHHrocKonnH.
10. Onmunxe xexHHKy npOBefleHMn HenpnMOM napuHrocKonnn.
11. OnHWMxe rexHMKy nposeAeHMfi OTOCKOHMH.
12. B H6M oi^MHue napnHrocKonnMecKoii KapxHHbl npw np^MOii M nenpaMoii jiapHHrocKonnn?
flonofiHumenbHbie eonpocbl dna neduampuvecKoso (paKyfibtnema:
13. KaKOBbi oco6eHHocTM ocwoxpa JlOP-opraHOB y Aexeii pannero
Bospacra?
14. KaKMM o6pa3ow MO>KHO oGcxieflosaxb nocornoxKy 6es MHCXpyweHTOB?
If.-....
HOC M OKOJIOHOCOBblE
HA3YXM
— 1 80 MMHyx.
LJenb 3aH5iTMH. MsyMMXb MexaHH3Mbi peannsaqnn
cpM3nonorMH6CKMx cpyHKqMM Hoca na ocHOBe anaTOMOronorpacpMMecKMX oco6eHHOcieM PO^OCXM Hoca M npMflaxoMHbix nasyx noca. BbiflenMXb anaxowMMecKMe oco6eHHocxM cxpoeHMfl no/iocxn Hoca, npeapacno/iaraioLUM6 K P33BMXMIO XpOHMMeCKOTO CMHyCMXa.
1 . Pa3o6paib KnuHMHecKyio anaxoMMK) nonocxM Hoca,
na ocHosaHMM Mero o6ocHosaTb (pMSMonorMMecKyio po/ib
HocoBoro Knanana, ocxMO-weaxajibHoro KOwn/ieKca.
2. MsyHMTb OCO6eHHOCTM APSHMpOBaHMH npMflaXOHHblX
nasyx noca B aaBucuMOCxn ox XORMKM coycxbes nasyx.
3. Bbiflennxb MexannsMbi pasemnfl pnHo-cuHycoreHHblX OCJIOWHeHMM.
flonosiHumefibHO dnn neduampuvecKoeo
4. MsyMMXb oco6eHHOcxM cxpoeHMfi HO/IOCXM noca,
npuflaxoMHbix nasyx noca M neperopoflKM Hoca
excKow Bospacxe.
JJonofiHumefibHO dnn cmoMamofiosuvecKoao
cpaKynbmema:
5. MsyHMXb xonorpadpMHecKMe oco6eHHOcxn anbBeooxpocxKa BepxneM Meniocxn M BepxHeHeniocxHOM nasyxM y flexeii M sspocnbix.
6. O6ocHOBaxb MexannsMbi passMXMJi oflOHXorenHbix
BocnanMiejibHbix 3a6oneBaHMM npMflaxoHHbix nasyx noca.
OcnaaieHMe. OcsexMxenbHbie npn6opbi: MCXOHHMK
csexa, no6HbiM pecp/ieKxop. flewoHcxpauMOHHbiM waxepMaxi: nxiaKaxbi, cxiaMflbi.
Ha6op MHCxpyweHTOB. HocoBbie sepKana, tunaxeJIM, HocornoxoMHbie sepKa^a, SOHAU HaBMBHbie,
HOCOBbie.
Tewa II. HOC M OKOJlOHOCOBbiE HASYXM
28
Pa6o<nee MCCTO. HHCTpyMeHxaribHbiM CTOJIMK, HacionbHan naMna, CTIMPTOBKa, flea cryna.
MecTo npoeeAeHwi aaHflTHH. y^e&nan KOMnaxa.
1. Condamoe M. 5. JleKtiMM no OTOpuHonapMHronornn. — M.:
1990.
2. UJeepbieuH E. B. PyKOBOflCTso no ASTCKOM OTopHHOJiapMHronormi. — M.:
MeflnqnHa, 1985.
3. OevuHHUKoe K). M. OropuHonapMHronornq. — M.: MeflnqnHa, 1995.
4. Hocyfin E. B. <t>M3Monornfl Hocoeoro AbixaHkin. — MpKyrcK, 2000.
I. OHSMOJlOrMHECKAfl POJlb HOCOBOfO flblXAHMfl
Hoc — MHoro(|>yHKH,HOHajibHbiH opran H snaqeHHe Kaayjon HS ero 4>yHKLU«i
opraHHSMa orpoMHO, noaxoMy HX xpyano pasaenHXb Ha raaBHbie H BxopocxeneHHbie. K ^ymcuHaM noca oxnocaxca: abixaxejibnaa, KOHflHUHomipyiomaa, samHXHaa, o6oHaxejibHaa, BKycoBaa, pesonaxopHaa, aie3onpoBO,zmaa H
cxaa.
.Ubixaxe.ibHaH <J>VHKHHH (pecnHpaxopnafl, BosflyxonpoBe/jeHHa).
<J>yHKH,HeH BosflyxonpoBOflamHX nyxefi xpa^HUHOHHO cnnxaexca xpaHcnopx
xaeMoro H BbmwxaeMoro Bosayxa. OflnaKO HOCOBOC awxaHHe npeacxaBJiaex co6OH aKXHBHMH 4>H3HOJlOrHHeCKHHllpOUeCC, KOXOpblH HC XOJIbKO OKaSblBaCX BJIHaHHC H3 CKOpOCXb H oSlBM BOSflyiUHHX HOXOKOB, HO H CnOCo6cxByCX OHHIIieHHIO H
KOHflHUHOHHpoBaHHK) nocxynaromero B ajibBeojibflBosflyxa. BosayiuHbie DOXOKH
BSaHMOflCHCXByiOX
C MHOrOHHCJieKHblMH HepBHWMH pCUCnXOpaMH CJIH3HCXOH
o6onoHKH, oGecnenHBaa HepBHo-pe(})neKxopHbie csasn HOJIOCXH Hoca c flpyrHMH
opranaMH H CHCxenaMH opraHHSMa. ^flHHM H3 OCHOBHUX (JiaKxopOB, peryjinpyroiuHX. Q&beM, cKOpocxb H xapaxxep BO3,ziyuiHoro noxoKa B IIOJIOCXH noca, asTiaexca HOCOBOC con|ioxHBJieHHe. B pesyjibxaxe coKpameHna ^bixaxenbHbix Mbiiiiu
"cbsAaexca rpa/iHeHx Mexcjiy antBeojiapHbiM H axMOC^epnbiM ^asneHHeM, KOXOpbifi nepeaaexca B nojiocxb noca.
yBCJimeHHe orpHuaxejibHoro aasjieHHa H noxoKa BflbixaeMoro Bosflyxa conpOBoayiaexca cy»ceHHCM HOCOBOFO Knanana H yBe^HHCHHCM ero HMneflanca. npH
MaKCHMajibHOM Bfloxe npOHCxoflHX Kojuiaffc KJianana. B 3XHX ycjioBHax AajibHeHiiiee Hapacxanne oxpnuaxejibHoro flaaneHHa He conpOBoayjaexca ysenmeHHeM HHcnHpaxopHoro noxoKa Bos^yxa. 3xa oco6eHHOCxb nosBOJiaex paccMaxpHBaxb HOCOBOH KJianan B KanecxBe nepBHHHOro peryjiaxopa nocxynaiomero Bosflyuinoro noxoKa. Enaroflapa ero aeHCXBrao nponcxoflnx saMCfljieHHe H yrjiyGjienHC flbixaHHa, HXO
cosflaex ycjioBHa /pa 34>4>eKTHBHoro ra3oo6MCHa, paBHOMepHoro pacnpeaejienHa
cyp<J>aKiaHxa B anbBeonax. CyMMapnaa Hocosaa pesHCxeHXHocxb — BemnHHa OXHOnocxoaHHaa, a B xeneHHe cyxoK Ha6raojiaK)xca UHKiiHHecKHe
I. 0M3MonornHecKafl po/ib HOCOBOPO AtixaHun
29
HOCOBoro conpoxHBJieHHa, H3-sa nero nepes o6e nojioBHHbi noca npoxoaax, KaK npaBHJIO, HeoflHHaKOBbie BOsayuiHbie HOXOKH. TaKHe nepHOflHHecKHe KOJie6aHHa HOCOBoro conpoxHBJieHHa oGycjioBJieHbi cocxoaHHeM xonyca nemepHCXbix cruiexeHHH HOcoBbix paKOBHH. <t>H3HonorHHecKoe SHaqeHHe 3xoro MexaHHSMa CBasbisaiox c BOCcxanoBHxejibHbiMH H KOMneHcaxopHbiMH npoueccaMH HOCOBOH nojiocxH. naxonoraH3MCHeHHa oGnacxH HOCOBOTO Knanana BbBbmarax saxpy/iHeHHe HOCOBOPO
a, napyuiaiox Hepe^oBaHHe GnojiorHHecKHX nponeccoB B oSenx nojioBHnax
Hoca, cos^aBaa npeanocbuiKH K 4>opMHpOBaHHK> (j)yHKUHOHajibHbix H naxonorHHeCKHX HSMCHeHHH B HOCOBOH HOJIOCXH H OKOJIOHOCOBHX H33yXaX.
Ha Bfloxe, nponaa o6:iacxb HOCOBOFO KJianana, OCHOBHOH HOXOK Bos^yxa nanpaBJiaexca K cpe/ineMy HOCOBOMy xofly H pacnpe/iejiaexca B cpe^HCM H BepxHCM
oxflene nonoicxH noca (npHMepno 80% ycnoBHbix e^KHHu). HpH CHOKOHHOM
'B^oxe xoubKo OKOJIO 20 % ycnoBHwx CAHHHII BflbixaeMoro sos/iyxa npoxoanx
nepes HIKKHHH HOCOBOH xofl. Jl£H_ np_HHifojHjBajHHH o6i>eM Bos^yxa, HanpaBJiaiomeroca K Kpbiuie HOJIOCXH noca, yBenHHHBaexca. IlpH Bbwoxe OCHOBHOH IIOXOK
Bosayxa, BsaHMoaeficxBya co CBOJIOM HOCOFJIOXKH, saflHHMH^KOHuaMH HOCOBHX
paKOBHH, nanpaBjiaexca B HH»CHHH HOCOBOH xoa (~ 80 %). B cpenmim H B sepxHHH HQ£.QB,bLe xoflw nocxynaex npHMepno 20 % Bbi^bixaeMoro Bosayxa lipeiiMymecxBCHHO B BH^e xyp6yjieHXHbix HOXOKOB! HOCOBOC conpoxHBJieHHe Ha Bbmoxe
OKasbiBaex xopMOsamee BJinaHHe Ha CKOpocxb flEHKCHHa BbiflbixaeMoro
Ho Mepe napacxaHHa ero aaBJieHHa nponcxoanx pacmnpeHHe KJianana H
uieHHe aaBJieHHa B HOCOBOH HOJIOCXH. ripn npoxo»meHHH BflwxaeMoro
nepes CHCxeMy HOCOBHX XO/JOB H cyaceHHH B HOCOBOH HOJIOCXH HaGnioAaexca naMHHapnoe (CJIOH Bos/iyxa ^BHacyxca napajuienbHO apyr flpyry H cxeHKaM HOCOBOH HOJIOCXH) H xypGyjienxHoe (xaoxHHHoe) aBHaceHiie npToicpB. JlaMKHapnoe
^BHaceHHe BOSHHKaex npn HH3KOH, a xyp6yjieHXHoe npn BHCOKOH o6i.eMHOH CKOpocxH noxoKa sosayxa. Bjiaro^apa xypSyjienraocxH Bxoaamero Bosaymnoro noxoKa coflepacamneca B B03flyxe Kpynnwe nbijieBbie nacxHUbi, MHKpoopraHH3Mbi
ocajiyjaioxca na cxcHKax nepe/jHHX OX/ICJIOB HOCOBOH HOJIOCXH.
3aiuHTHasi <J)VHKHHH. CoraacHo cospeMenHbiM npcAcxaBneHHaM, or ypoBHa
sarpasHCHHOcxH BflbixaeMoro Bos^yxa saBHcnx BosHHKHOBCHHe 6ojiee 30 % cjrynaes HHeBMOHHH, OKOJIO xpexH ocxpwx pecnnpaxopHbix 3a6ojieBaHHH, 6ojiee
20 % cjiynaeB 6poHXHajibHOH acxMbi. YflejibHWH aec sarpasneHHOcxH Bos^yxa
KaK 4>aKXOpa, cnoco6cxByiomero BO3HHKHOBeHHK> naxojiorHH opranoB abixanna,
cocxaBJiaex 50 %. Flpn a^eKsaxnoM JICFOHHOM rasooGMene nepes nojiocxb Hoca B
cyxKH npoxo^HX OKOJIO 17000J1 Bosayxa. B HOCOBOH DOJIOCXH sa^epHCHBaioxca
npaKXHHecKH BCC BflbixaeMbie nacxnubi ^HaMexpOM 6ojiee 8 MKM, Sojiee HOJIOBHHbi BCCX nocxynaromHX nacxnu flnaMexpOM SoJiee 2 MKM. Ha nosepXHOcxH CJIH3HCXOH o6ojioHKH oceflaex 6ojiee 60 % MHKpoopraHHSMOB BflwxaeMoro Bosayxa.
H oGesBeHCHBaHHe xaKoro_orrJOMHoro_p6i.gM<§ Bo,3;jy^a o6ecneiHBaexca
i: 6apbepnaa
, MyKOUHJIHapHblH I<^Hpe«C~cTH3HCXOH"o6oJIOHKH HOJ1OCXH HOCa,
TeMa II. HOC H OKOJlOHOCOBblE HASYXM
30
Hbie cBOHcxBa HocoBoro ceicpexa, HeHpo-petJmeKxopHbie MexaBHSMbi
cjiesoxeneHHe, HHxaHHe, OXCK HOCOBbix paKOBHH.
Ko>Ka npezmBepna Hoca coflegacHX.fiOJioeH, Koxopwe saaepxcHBajox jcpynHbie
nacxHiibi nwjiH, ca>KH H x. A Eapbepkwe ~<|)yHKU,HH CJIHSHCXOH o6o:iOHKH csasaHbi
c MyKoumiHapHbiM KJinpeHCOM (nepBaa JiHHHa sainHiu) H co6cxBCHHOH nnacxHHKOH CJIHSHCXOH (Bxopaa jiHHHa samnxbi).
Ha nosepxHocxH KaxmoH 3HHxejiHaJibHOH KJICXKH CJIHSHCXOH o6ojionKH flbixaXejibHOH o6jiacxH HMeexca ox 50 flo 200 pecHHHCK, coBepmaiomHX KOJie6axeJibHbie ABH>KeHHa. Ka^woe ^BH»eHHe PCCHHHKH COCXOHX HS asyx 4>as — nocxynaxejibHOH H BOSBpaxnoH. B nepByio^asy pecHHHKa BbixarHBaexca, ee sepxyuiKa flocxnraex noBepxHOCXHofcTcjioa HOCOBOFO ceKpexa, Koxopbifi 6ojiee rycXOH, HCM noflJiexamHH CJIOH, H npo^BHraex ero B nanpaBJienHH HOCOHIOXKH.
TojibKo na HeGojibiuoM ynacxKe cjiroHCxofi, npHJie^KamcH K npeAflBepHK) noca,
HOCOBOH ceKpex BbiBOflHxca B npe^flBepHe. AKXHBHOCXb MyKOUHJiHapnoro xpancnopxa saBHCHx ox cocxoaHHa HOCOBOTO cenpexa. IIpH CHH^KBHHH HJIH noBbiuieHHH
Ba3KOCXH cexpeia, yMCHbiiieHHH HUH yBejiHHCHHH ero KOJinnecxBa cnnxpOHHOcxb
KOJie6aHHH pecHHHCK, noABH»cHOCxb nosepxHOcxHoro ciioa Hapyuiaexca H cosaaioxca ycnoBHa ana HapyuieHHH roMeocxasa CJIHSHCXOH o6o;ioHKH. HpesBbiiaHHO BaacHbiM ycJiOBHCM AJW (J)yHKUHH pecHHXHaxoro annxejina aBJiaexca <J>H3HOJioFHHHOe HOCOBOC flblXaHHC.
HOCOBOH ceKpex COCTOHX H3 npo^yKXOB »H3HeaeaxejibHocxH HCCJICS CJIHSHCXOH
o6onoHKH H xpanccyAaxa. B <j)H3HOJiorHHecKHx ycjioBHax cyxonnaa nppflyiaiHH HOcoBoro ceKpexa cocxaBJiaex ox 0,5 flo 1 Ji, a xojuinma ero cjioa cocxaBJiaex OKOJIO
5-10MKM. Ha 95 % HOCOBOH ceKpex COCXOHX ro BOflbi, xaic«e B cocxas Bxoflax
npoxeHHbi, yrjieBOAbi, JIHIIHZIH (4>oc(J)OJiHnHflbi H cyp^aKxanx), 3jieKXpoJiHXbi. 3amnxHbie CBOHCXBa HOCOBOFO ceKpexa CBasanw c pacxBopenHbiMH B HCM <J>aKxopaMH
ecxecTBCHHOH pesHcxenxHOcxH H cneuHtJiHHecKoro HMMyHHxexa. K <J>aKxopaM ecxeCXBCHHOH pe3HCXCHXHOCXH OXHOCaXCa: J1H30UHM, KOMHJieMeHX, JI3KXO(J)eppHH, HH-
xep4>epOHbi, (J)arouHXHpyK)UiHe IOICXKH, MexamionpoxeHflbi.
JJuscmuM (apyroe HassaHHe — MypaMH^asa) — <J>epMeHx, pacmemiaiomHH
MypaMHHOByro KHCJioxy, Bxoaamyio B cocxas oGonoHKH rpaM-nojio»HxejibHbix
6aKxepHH, cnocoGcxByex nH3Hcy GaKxepnanbHOH CXCHKH.
KoMwieMenm — KOMHiieKc cbiBOpoxoHHbix GCJIKOB, ynacxByiomHH B JIHSHCC
GaKxepHH, HHaKXHBauHH 3HAOXOKCHHOB, HCHXpajiHsauHH BHpycoB, yMacxByex B
aKXHBauHH 4)arouHXHpyiomHX KJICTOK.
JlaKmocpeppm — 6enoK cneiiH(J)HHecKHX rpanyji HefiipocJjHJioB. Bamnxnoe
CBasano co CBasbiBanneM Fe3+, Koxopoe neo6xoAHMO AJM HOpManbHoro
MHKpo6HOH KJieXKH.
HnmeptpepOHbi — npoayunpyioxca JiHM(J)OUHxaMH (a-HHxep^epOHbi) H (})H6(p-HHxep<JiepoH), no^aBnaiox xpancjiflUHio BHpycHofi MPHK, o6pasyrox H3 HeHH(})HUHpoBaHHbix KJICXOK 6apbep BOKpyr onara BHpycHoii
orpaHHHHBaa ee pacnpocxpaneHHe.
I. On3HonornMecKaa ponb HOCOBOTO flbixaHkin
31
K KJiemKOM <pazomimapHOU cucmeMbi oxHOcaxca Henxpo^Hnbi, MOHOUHXW H
MaKpo4>arH. OHH norjiomarox H paspyuiaiox GaKxepnanbHbie toiexKH, oGpasyrox
aKXHBHbie (J>opMbi KHcnopoaa, oGna/iaiomHe ^ecxpyKXHBHWM CBOHCXBOM B OXHOiiieHHH MHKpoopraHH3MOB H noBpe»weHHbix xKaneH.
Memajuionpomeudbi — Fe- H Cu-coaepacamne 6ejTKH, no^iiep^cHBaiomHe aKXHBHOCXb 4>aroiJHXapHOH CHCX6MH, H BMCCXC C XCM oSeCHCHKBaiOIUHe aHXHOKCH-
^aHXHyro sauinxy HenoBpe>iaieHHbix XKaneH opraHHSMa B onare BocnanenHa ox
aKXHBHblX MCXaSoJlHXOB KHCJIOpO^a.
OaKxopbi cnei(H(J)HHecKoro HMMyHHxexa npeflcxaBneHH coaepacamHMHca B
HOCOBOM ceKpexe HMMyHonio6yjiHHaMH A, M, G, E.
IgA nrpaex Beaymyio ponb B o6ecneneHHH MCCXHOFO HMMynnxexa HOCOBOH
OOJIOCXH: npenaxcxsyex a^resHH GaKxepnajibKbix KJICXOK K 3nHxejiHio CJIHSHCXOH
oGonoHKH, noxenuHpyex aKXHBHOcxb jiroouHMa, KOMHJieMCHxa, aKXHBHpyex <J>arouHXHpyromHe KJICXKH.
IgG y^acxsyex B oncoHH3ai;HH MHKpo6oB, HCHXpanHsauHH GaKxepnajibHux
XOKCHHOB.
IgM ynacxByex B HeftxpanHsauHH XOKCHHOB, npoueccax arrnioxHHauHH, oncoHH3auHH, npenaxcxByex aaresHH 6aKxepHH na CJIHSHCXOH.
IgE npo^yiiHpyexca xynnbiMH KJiexKaMH CJIHSHCXKX, y^acxByex B aKXHBau.HH
a. <t>H3HonorHHecKaa po^b IgE nsy^cHa neflocxaxoHHo. Ero co^epB cjiH3HCXbix o6ojioHKax HBJiOBeKa BCJIHKO Ha cxaflHH BHyxpHyxpoGHoro
. noBbimeHHbiH ypoaeHb IgE nocne poameHna paccMaxpHBaexca KaK
4>aKxop, npeapacnojiaraiomHH K pasBHxnio aiuieprHHecKHX peaKUHH.
B (})OpMHpOBaHHH OCHOBHOH HJiaCXHHKH CJ1H3HCXOH oSoJIOHKH HOC3 GoJiee
XpCXH BCCX KHeXOK COCXaBJWIOX JlHM(J)OLlHXbI. FIpH BSaHMO^CHCXBHH C aHXHrCHOM
npoHcxo/iHx xpanc<})opMauHa B-JIHMI^OUHXOB B ruiasMaxHHecKHe KJIBXKH, KOXOpbie npoayuHpyiox cneqH<J)HHecKHe ana aaHHoro anxHrena anxHxejia, raasHbiM
oGpasoM — IgA, nocxynaromHe na nosepxHOCXb CJIHSHCXOH HOCOBOH HOJIOCXH.
Pe<J)jieKxopHbie BjinaHHa co CJIHSHCXOH oGojiOHKH noca ynacxByiox B peajnoamm
samHXHbix 4>yHKiiHH. HanGojiee BbicoKoii HyBcxBHxejibHocxbK) oxjinnaroxca pe4)JieKcoreHHbie SOHW HOCOBOH nojiocxH — o6nacxb npe,zmBepna noca, BepxHHX HOCOBbK
xoaoB H flopcanbHaa noBepxHOCxb HHXCHHX nocoBbK paKOBHH. PasapaxceHHe peuenXOpOB HOCOBOH IIOJIOCXH npOHCXOflHX BCJieflCXBHC flaBJICHHa BOSayiUHbK riOXOKOB,
BosflCHCXBHa coflepMcamnxca B HHX HbuieBbK nacxHu, XHMHHCCKHX seiuecxB, a xaicace
xeivmepaxypbi BflbixaeMoro aosayxa. B oxsex Ha pasflpaacenne oKOHHanHH xpoHHHHHoro Hepaa ycHJiHaaexca cjiesoxeneHHe. HonaflaHHe CJICSHOH >KHJIKOCXH B HOC nrpaex
Baacnyio pojn, B yaaneKHH nppnxaHxa co CJIHSHCXOH noca. CxHwyjiaoHfl peuenxopos
HOCOBOH neperopoflKH, HH^CHCH H cpeaneH HOCOBWX paKOBHH^ieflex K BOSHHKHOBCHHK) HHxaxejibHoro pefJiJieKca, conpOBoxqiaiomeroca coKpameHHCM 6poHXHajibHOH
MycKyjiaxypbi, noBbmieHJieM BHyxpnipyflHoro flaBJieHHa, BHCOKOH JIHHCHHOH cKOpocTbio BosjiyuiHoro noxoica B saKJuowrejibHOH 4>a3e HHxaHHa. AKXHBHyio ponb B peaJiHsauHH HHxaxejibHoro pe(J)jieKca mpaex o6oHaHne.
32
TeMa II. HOC M OKOJIOHOCOBblE HA3YXH
Pe<|>JieKCbi HS HOCOBOH IIOJIOCTH, BOSfleficxBya Ha flbixaxejibHbifi nenxp, ynaB peryjiauHH flbixaHHa. PasflpaweHHe peuenxopoB Sjiyayiaiomero Hepsa
conpOBO5K#aexca ynameHHCM H yMCHbiiieHHeM rjiy6HHbi /juxaHHa, a XPOHHHHHOro H o6oHaxejibHoro — ssMCflJieHHCM H yrjiySjieHHCM flwxaHHH. OGoHaxejibHaa
TpOHHHHHOrO HCpBa MO5K6T COHpOBOJKflaXbCa 33,Ziep>KKOH flblXEHHS, a
pesKoro sanaxa cnocoGno Bbi3B3Xb ocTanoBKy jnjxaHHa. Peuenxopw
HOCOBOH nOJIOCTH BSaHMOflCHCXByiOX C CCHCOpHblMH CHCXCM3MH HH»ejie>KamHX
jlbixsxejibHbix nyxeH. HanpHMep, pasApsaceHHe CJIHSHCXOH oGonoHKH HOCOBOH
nonce™ coaepacaiUHMHca B Bosjiyxe nacrauaMH HHJIH conpoBo>Kflaexca yBenHTpaxeo-6poHXHajibHoro conpoxHBJieHHa (pHHo6pOHXHajibHbiH pe<f>Jieicc).
3TOM B036y}K£eHHe nepeaaexca no BOJIOKHaM CCHCOPHOH nopUHH xpOHHHHHOFO Hepsa K aflpy V napbi B CTBOJIC Mosra, 33TCM K n. ambiguus H B cocTase BOJIOKOH 6jiy>Kflaiomero Hepsa K nepe/jHCMy H sa^neMy JieroHHOMy ciuiexeHHK).
CymecTByeT eme ojib4>aKxo-6pOHXHajibHbiH pe<})JieKc — B SXOM cjiynae HSMeneHH6 SpOHXHaJIbHOrO COnpOTHBJICHKH BO3HHKaCT B OTBCT HE o6OHaTCJIbHyiO CTHBuHflHHC pasapaKCHHS HCpBHblX OKOHHaHHH HOJIOCTH HOC3 Ha pHTM
coKpameHHH peaJiH3yeTCH B BH^B pHHO-Kap^HajibHoro pe4uieKca nepC3 BaaHCB H TpOHHHHHHH HCpBbl, BCpXHCC CJHOHOOTflejIHTCJlbHOe HflpO C HCpe-
ero na aopcajibHoe aflpo 6jry»yiaiomero Hepaa H nocneflyiomHM BOSna cepaue. PasapaxceHHe peuenTOpos CJIHSHCTOH HOJIOCTH noca OKasbisaeT peryjiHpyiomee BJinaHHe na jiHKBopo/iHHaMHKy B HOJIOCTH nepena.
BcJieflCTBHC nepeHHCJICHHblX npHHHH BSaHMO^eHCTBHa BOSflyiUHblX nOTOKOB
c peijenTopaMH CJIHSHCTOH noca H BO3HHKaiomHe npn STOM cy6i,eKTHBHbie omymeHHa OKasbisaiOT cymecTBCHHoe BJinaHHe na KanecTBO XCHSHH.
KoHflHUHOHHpOBaHHe BOSflyxa. KoH^HUHOHHpOBaHHe BOSflyxa noApasyMCBaex ero corpjeBaHHe H ^BJiEgKHeHHe^ CorpeBaHHe oGecnenHBaerca HSMCHeHHCM npoCBera HocoBbix .XOHQB B saBHCHMOcra OT TeMnepaTypbi BflbixaeMoro sosayxa H sa
CHCT cMeuiHBaHHa nocTynaiomero Bos^yxa c aos^yxoM, naxoflamHMca B OKOJIOHOCOBWX nojiocxax. YBe^HHeHHe oSteMa HOCOBbrx_£aKOBBH (H
cyaceHHe npocBera riocbBbix xbflOB) nponcxoflHT pe(J)jieKTopHo npH
I. 0H3MOJ10rMHeCKafl po/lb HOCOBOrO flblXaHMfl
33
OGOHHHHC. HCJIOBCK H HpHMaTbl OXHOCaXCa K MHKpOCMaXHK3M B CHJiy OTHOCH-
cna6oro pasBHTHa oprana oSoHamia B ornnHne or GojibiiiHHCTBa JKHBOXHHX
(MaKpocMaxHKOB). TeM He Menee, oGoHaraie y HejioaeKa Hipaex BajKHyio pojib B peanHsaiiHH immeBofi, IIOJIOBOH, oxpanHxenbHOH, OPHCHTHPOBOHHOH 4>yHKmm. 06oHaxejn,naa (})yHKUHa y nejiOBCKa BKjuoHaex asa BsaHMOflonojiHfliomHX KOMnoHCHra: BocnpnarHC H ,OH4KJ>epeHiaiauHK> sanaxoB. ^HanasoH noporoBbix KomreHxpaipra naxynnx
BemecxB Boaayxe, BocnpHHHMaeMbix HenOBCKOM, onenb BCJIHK: ox 10~13 flo 10~3 MOJib/n.
HMeexca 3aMexHbiH HH^HBH^yanbHWH paaGpoc B HyBCTBHxejibHocxH jnoaefi K sanaxaM H B HX re^oHHHecKOH oueHKe. meHTgajibHbie pGoHarejibHbie oGpaspBaHHa xecno
CBasanbi co CTBOJIOM Mosra^ HXO o&bacnaex HSBecxHoe BjmaHHe sanaxoB na 3MOUHOHanbHoe cocxoaHHe nejioBCKa, ero pa6oxocnoco6Hocxb. npnaxHbie aanaxn nOBbiuiaK)X TCMnepaxypy KO»H, CHKracaiox apxepnaiibHoe aaaneHHe, ype)Kaiox nacxoxy cepACHHHX coKpameHHH, noHKacarox BHyxpHHepenHoe /laBJieHHe. HenpHarm>ie sanaxn
OKasbmaiox npoxHBonojio^cHoe aeHCTBHe. ^CJIOBCK cnoco6eH BOcnpHHHMaxb 6onee
10 000 sanaxoB, Kaacflbift H3 Koxopbix MOXCCX BoaGyanxb HJIH noracHXb annerax, HSpa6oxocnoco6HOCTb. AccouHaima aanaxa HBCTOB, /iyxoB H np. c HH<J>opMa, HaxoflameKca B noacosHaHHH, MOHCBT OKaswBaTb asnoe 3pOTHHecKoe BJiHamie.
HapymeHMe oGonaHMa cxanoBHTca cepbeanoH npo6jieMOH AJIH OAHHOKHX jiro/ieH, xaK
KaK xepaexca cnocoGnocxb onpe^enaxb KanecTBO rmmeBbix npo^yicxoB no aanaxy,
npHcyxcTBHe B noMeiueHHH 3anaxoB rapn HJIH rasa. BicycoBaa pojib oGoHanna csasana c nonaaaHHCM naxynnx 3JieMCHTOB nmuH nepe3 HocoraoxKy B nojiocxb noca.
BKycosaa H oGonaxejibHaa peaenuna GJITOKH no 4)H3HOJiorHHecKOH (JjyHKUHH, npnHBM Be/iymHM asjiaexca oSoHaxejibHbiH pecjjjieKC «Ha p3ccxoaHHH», a KOHxaKTHbiH
BKycoBOH pecJmeKC — KOHrpojiHpyiomHH.
HCJIOBBK oSjiaflsex HHaHBHayanbHbiM sanaxoM. Xopomo HSBCCXHO, HTO
sanax nejiOBCKa 6e3ouiH6oHHo ysnaexca xpeHHpoBaHHbiMH co6a. OGoHanne nejiOBCKa xaicace cnoco6no (HO B MCHbiueH cxeneHn) pasjiHHSTb
no HuzjHBHflyajibHOMy sanaxy, B nacTHOCTH, nosBOJiaex ysHasaTb no sanaxy
GJIHSKHX PO^CTBCHKHKOB. HH^HBHayajitHbie aanaxoBbie KOAH nejioseKa
H XCHBOTHbK nOK3 HC paCUIH^pOBaHbl, BO3M03KHO, HTO KOMHOHCHTaMH SanaXOBOFO
XOHOAHblM BOSflyXOM OKOHHaHHH TpOHHHHHOFO HepB3. fMeiUHBaHHe
KOfla aBJiaroxca nsoMepu BHCIIIHX »oipHbix KHCJIOT, oGjiaaaiomHe SojibiuoH MOJieKy-
Bosayxa H B03^yxa nasyx noca nponcxoflHT Gnaro^apa nocoBOMy KJianany, xaK KaK
BO Bpeisia B^oxa B HOUOCTH noca oGpasyerca oxpHuaTejibHoe flaBJieHHei HTO BbBbiBaer nepeMemeHHe corperoro Bos^yxa H3 nasyx B no^ocTb noca. 3KcnepHM6H-
JiapHOH M3CCOH H HH3KOH JiexyHCCXbK). HsGjnOaCHHa H3JJ MCXaHHSMOM CBKCySJIbHOrO
B03«yxa -12° B HOJIOCTH HOCOHIOTKH xeMnepaxypa noBbiuiaerca ao +25°.
HCHHe BflbixaeMoro Bosayxa nponcxoflHT npn HcnapeHHH BnarH c noBepXHOCTH
npeanoHxcHHa y HCJIOBCKS yKasbmaiox Ha BO3MO)KHyio pojib mmHBH^yajibHoro 3an3xa My»HHHbi B Bbi6ope HCCHIUHHOH cynpyra HJIH HOJIOBOFO napxHepa. Onpocbi noKa3biBaiox, HXO Ana HceHmHHbi sanax napxnepa HMCCX 6ojibiuee SHaneHHe, HBM ana
MyacHHHbi. ^CeHuiHHbi npeflnoHHxaiox sanaxn MyKHHH, Koxopwe HenoxoacH Ha HHX
no CBOHM renaM racxocoBMecxHMocxH, o^HaKO sxa ocoGeHHocn. HHBepTHpyexca, ec-
CJIH3HCTOH O60JIOHKH. HpH (J)H3HOJIOrHHHOM HOCOBOM flblXaHHH B TCHCHHC CyTOK CO
JIH acCHUIHHa npHHHM3CT rOpMOH3JU>Hbie KOHTpan,enTHBbI.
TailbHO nOK33aHO, 4TO npH (J>H3HOJIOrHHHOM HOCOBOM flblXaHHH npH t° Bflbl
CJ1H3HCTOH O60JIOHKH HO^OCTH HOCa HCnapaCTCa OKOJ10 400 MJI BOflbl. IIpH HOBbl-
TeMnepaTypbi Bos^yxa HcnapeHHe npoHcxo^HT Gonce HHTCHCHBHO. npH
HOCOBOM fltixaHHH oTHocHTCJibHaa BnaxcHOCTb Bosflyxa, nociynaiomero nepes noJiocTb Hoca B Tpaxeio, cocxaBjiaer 95 %.
o6oHHTejibHaH cHCTCMa. SnanHMyio pojib B peryjiaiiHH
penpOAyKXHBHOH CHCXCMW H nojiosoro noBe^eHHa nrpsex aonojiopran o6onaHHa — BOMepo-HasanbHbiH opraH (JlKoSconoB opran). Y
HCHBOXHblX OH OHHC3H B 1811 T. JIlOflBHrOM ^KOGCOHOM
34
TeMa II. HOC M OKOJIOHOCOBblE HASYXM
B BOMepo-HasajibHyio cncxeiviy BXO^HX: 1) BOMepo-nasanbHWH opran (#Ko6coHOB opran); 2) BOMepo-HasaribHbiH Heps; 3) jiHMo'HHecKaa CHCxeMa ronoBHoro MO3ra. V HCJioBeK3 5hco6coHOB opran napHbifCpacnojiaraexca B nepe^HeH xpexn nepeHoca, Ha rpaHHue xpameBOH H KOCTHOH ee nacxeft, na 1-2 CM AopcajibneH
H na 1 MM Bbime fl.ua OOJIOCXH Hoca. OxKpbiBaexca .HicoGcoHOB opran
B nonocxb Hoca oBanbHOH H OKpyrjioft aMKOH, jiOKanroyiomeHca 1 -2 CM KsaflH ox
saflnero Kpaa Hos^pH. HMeexca 6ojibmoe KOJIKHBCXBO anaxoMHHecKHX BapnaHXOB
crpoeHHa, pscnojioaceHHa H paaMepoB ycxba .HKo6coHOB3 oprana. Ycxbe se^ex B
KOpoxKHfi Kanaji, npoxoflamHH MCAHanbHO B CJIHSHCXOH o6onoHKe nonocxH noca,
npoGoAaex coGcxseHHyio njiacxHHKy CJIHSHCXOH H naex Bbime nepHxouzipHa.
KJICXKH snHxejiHa 5lKo6coHOBa oprana, B OXJIHHHC ox pecHnxnaxoro 3HHxejiHa
jjbixaxejibHbix nyxefi, He HMCIOX pecHHHCK, HCXHHHbie 6oKajiOBH,nHbie KJICXKH oxcyxcxByiox. SiraxenHH flKoScoHoaa oprana oGjia/jaex KanecxBaMH, xapaKxepnbiMH flJia HepBHHX H HCHpO-SHflOKpHHHblX KJICXOK.
II. KJ1MHMMECKA51 AHATOMUfl HOCA M HPHAATOHMblX
RA3YX HOCA
Ilpexme HCM nanaxb H3JioaceHHe yne6Horo Maxepnajia, Heo6xoflHMO ocxaHOBHXbca Ha noHHMaHHH xepMHHa «KJiHHHHecKaa aHaxoMHH». Ha npeAiuecxByiouiMx
Kypcax Bbi nosnaKOMHJiHCb c xaKHMH OTCUHiuiHHaMH, KaK HOpManbHaa, naxojiorHnecKaa, xonorpa<J)HHecKaa anaxoMHa. B o6jiacxb nnxepecoB KJiHHHHecKOH aHaxoMHH BXOflHX aHaXOMKHCCKOe o6oCHOBaHHC BOSHHKHOBCHHa XOFO HJIH HHOFO CHM-
nxoMa saGojieaaHHa, xonorpa(j)HHecKoe oSocnoBaHHe BOSHHKaiomHX OCJIOMCHCHHH,
nporaocxHHecKHX npHSHaKOB. YcneuiHoe ocBoeHHe KJiHHHHecKOH aHaxoMHH HCBOSMOaCHO 6C3 XBCpflHX SHaHHH HOpMajIbHOH H XOnOIpa<|)HHeCKOH aHaXOMHH B COHCXaHHH CO 3HaHH6M THHOBblX naXOJIOrHHCCKHX npOUeCCOB, naXO(J>H3HOJIOrHHeCKHX
MexaHH3MOB pa3BHxna saGojieBaHHH. KjiHHHHCCKaa anaxoMHa K&K HHKaKOH flpyroft
pasACJi MeflHHHHbi cnoco6cxByex pasBHXHK) KJiHHHHecKoro MbiuuieHHa.
Hoc. Bbiflejifliox HapyacHiui HOC H nojiocxb Hoca. IlHpaMHfla napyacHoro HOca aBJiaexca OCHOBHMM yKpauieHHCM apxnxeKxypHoro ancaM6jia Jinua,
HaH6oJibuiee KOJIHHCCXBO HJiacxH^ecKHx onepauHH na jinue CBasano c
eft (J)opMbi napyacHoro noca. IlHpaMHjia noca HMCCX Kopenb, ox^ejieHHbiH oxo Ji6a
BbieMKoft — nepeHocbeM, xaicsce Bbijtejiaiox cnHHKy noca, 6oKOBbie CKEXW COHHKH Hoca, Kpbuiba Hoca, nepe^HHe nocoBbie oxBepcxna HJIH Hos/jpH. CKCJICT HapyacHoro noca HMCCX KOCxnyK) H xpameByio ocHosy: KOCXHHC CXCHKH nnpaMHAH
Hoca npeflCxaBJieHti Jio6HbiM OXPOCXKOM BepxHeft HejirocxH, HOCOBHM oxpocxKOM
jioSHoft KOCXH, HOCOBOH KocxbK). Bee KocxHbie o6pa3OBaHHH — napHbie. Xpamesaa ocHOsa npeACxaBjiena 6ojibiiiHM H ManbiM xpamaMH KpblJIbeB, GOKOEMM xpaIUOM. 3xH oGpasoBaHHa xaicace napnue. OOMHMO GojibiiiHX xpameft B (jjopMnpoB3HHH 4>opMbi napyacHoro Hoca ynacxByiox MBJIKHC CKomieHHa xpameBOH XKa-
II. KnMHMHecKaa
35
Hoca M npn,qaTOMHbix naayx noca
HH — cecaMOBH/iHbie H floGasoHKbie
(pnc. 8). Csepxy HOC noKpbix KoaceK, noa HCH
HaxoflHXca XOHKHH CJIOH MbiuienHOH, 4>H6posHOH, MCHpoBOH TKaHH. Mbiumbi HapyacHOro Hoca npe/iHasHaneHbi fljia cacHMaHHa HOCOBWX
OTBCpCXHH
H
OXXaPHBaHHa
KHH3y
KpblJIbeB nojiocxH noca, coKpaiueHne SXHX
Mbiuiu oSecneiHBaex KOJiJianc HOCOBOFO KJianana. KpOBocHa6aceHHe napyacHoro noca
oGecneHHBaex rjiasHHHnsa apxepna (a. ophtalmics), flopcajibH3a HOCOBaa apxepna (a. dorsslis nssi) H jinueB3a 3pxepna (3. facialis).
BeHOSHbiH OTXOK ocymecxBJlaexca qepes
yrjiosyio H nacxHHHO rjiasHHHHyK)
i, HXO B pajie cjiynaeB cnoco6cxByex npn
H3rHOHXCJIbHbIX npOH6CC3X HapyaCHOFO HOC3
pacnpocxpaHCHHK)
HH^CKUHH
B
CHnycbi
XBCpflOH M03rOBOH oSoJIOHKH, B H3CXHOCXH
Puc. 8. HapyKHbifi HOC:
1
HOCOBafl KOCTb, 2
BCpXHHH
jiarepajiBHtiH xpsm, 3 — jiarepajibHbiH
xpam KpbiJia Hoca, 4 — cecamoBHOTbie
xp»mH, 5 —flo6aBOHHbiexpamn
B ncmepHcxbiH cnnyc. JlHM(J)ooxxoK H3 napyacHoro noca ocymecxBJlaexca B no/iHejnocxHbie H BepxHHe OKOJioyuiHbie JIHM4>3XHMecKHe y3Jiw. ^BHraTejibHyio HHHepBaiiHio Hapyacnoro noca o6ecneqHB3er
JIHUCBOH HepB, HyBCXBHXeJlbHyiO
I H II BCXBb XpOHHHHHOrO HCpBa.
AnsxoMHa nojiocxH HOCS 6ojiee cjioacnaa. FloJiocxb eoca pacnonsrsexca MCaciry nepeaneH nepenHOH HMKOH csepxy, raasHHuaMH — jiaxepajibno H nojiocxbio
pxa — cHHsy. CnepeziH nojiocxb noca oxKpbiaaexca BO BHCUIHIOIO cpejjy nocpejjCXBOM H03JJPCH, C33J4H
COo6lU3eXCa C HOCOrjIOXKOH HCpC3 X03HU (33flHHe HO-
coBbie oxBepcxna). HajiHHHe oSmnx CTCHOK c nojiocxbio nepens, op6HX3MH, a
xaKace MHoroHHCJieHHbie 3HacxoMO3bi Meacjjy cocyaaMH GaccefiHOB napyacHOH H
BHyxpeHHeH COHHOH spxepHH o6ycjiOBjiHBaiox onacnocxb paasHXHa BHyxpHHepennbix H opGnxajibHHX ocjioacneHHH npn BocnajiHxeJibHbix 3a6ojieBaHHax noJIOCXH Hoca. B reHese BHyrpHop6HxanbHbix ocJioacHCHHH Han6ojiee XHOKHHWH
nyxb npOHHKHOBCHHa HH^CKUHH — KOHxaKXHbiH, xaK KaK o6m,aa CTCHKS rjia3HHHbi H nojiocxH HOCS — 6yMaacHaa njiacxHHKa pemexnaxoH KOCXH — 4pe3BbiHaHHO
XOHK3. PaCnpOCXpaH6HHe HH^eKUHH B CHHyCbl XBCp/IOH M03FOBOH oGoJIOHKH
ocymecxBJiaerca npeHMymecxseHHO reMaxorcHHbiM nyxeM nepes rjiasnyio Beny.
Bbiaejiarox npe/iiiBepHe nojiocro Hoca H HenocpeflCXBCHHO nojiocTb noca. Ilpeflnojiocra noca orpanHHCHO cnapyacn CBoGoflHbiM KpseM H03^peH, MeflH3JibH3cxbio HOCOBOH neperopoflKH, HSHyxpH — BHyxpeHHCH noaepxHOcxbio KpbuibeB noes. BwcxjiaHo npeAOsepHe DOJIOCXH HOCS Koacen, xaKOH ace KSK Ha
jiHue. Koaca cojjepacnx BOJIOCM, canbHbie H HOXOBWC acejiesbi, HXO o6ycjioBJiHBaex
BOSMOacHOCXb o6pa3OB3HHa 43ypyHKyjiOB npeJWBepHa noca. AH3XOMHHecKyio 06b, BKJiioHaioinyio B ce6a yroji Meayiy HOCOBOH neperopoflKOH H HHaooiM KpaeM
36
Tewa II. HOC H OKOJIOHOCOBblE HA3VXH
BepxHero JiaxepanbHoro xpama, nepeflHHH KOHCU. HH^CHBH HOCOBOH paKOBHHbl H
KHC xKann npe,naBepHa Hoca, Hasbisaiox HocosbiM KjiananoM. B HOpMe yron HOCOBOro KJianana paaeH 10-15°. HOCOBOH KnanaH nrpaex toiioHeByio pojn. B peryjiauHH
a, CKOpocxH H xapaKxepa Boa^yiiiHoro noxoKa B HOCOBOH HOJIOCXH.
FloJiocxb Hoca HMCCX Herwpe CXCHKH. BepxHaa cxeHKa (Kpwuia) B nepeflHHX
o6pa3OBana HOCOBWMH KOCXSMH, jio6HbiMH oxpocxKaMH BepxneH HCJIIOCXH H qacxHHHO nepneimHKyjiapHOH nJiacxHHKOH pemexnaxoH KOCXH. B cpeijHHX
ox/jejiax Kpwmy HOJIOCXH noca oGpasyex npOflbipaBJieHHaa njiacxHHKa peuiexHaXOH KOCXH, B saflHHX — KJiHHOBH/rHaa Kocxb (nepefliwa cxeHKa KJIHHOBHAHOH nasyxn). IlnacxHHKa pemexiaxoH KOCXH npoHHsana 25-30 oxBepcxnaiviH, nepes KOxopbie Hjiyx BCXBH nepeflHero peuiexnaxoro nepaa H Bena, conpoBoamaiomaa nepe^Hioio pemexnaxyio apxepnio H coe^HHaiomaa nojiocxb Hoca H nepe^Hioio nepenHyro aMKy. j-toKHaa_cxeHKa HOJIOCXH noca (flno) o6pa3OBaHa neGnbiM oxpocxKOM BepxHeii HCJIIOCXH B nepeflnnx ox,aenax H ropHSonxajibHOH ruiacxHHKOH He6HOH KOCXH B 3a^HHX oxflcnax. y nepeflHero Konua fl.ua HOJIOCXH noca HMeexca
HocoHeGnoro Hepsa H HOconeGHOH apxepnn, HflymnH B poxoByio nonocxb.
(MeflHanbHOH) CXCHKOH HOJIOCXH noca aBnaexca aocoBaa neperoIlepeflHHH 'arisen neperopoflKH noca npe/jcxaBjieH nexbipexyrojibHbiM
, BepxHHH Kpaft Koxoporo oSpaayex nepe^HHii ox/ieji COHHKH noca. B nepeflHe-HH>KHeM ox^ene xpam neperopoflKH Hoca npHMbiKaex K MeflHanbHOH HO>KKC Sojibmoro xpama Kpwjia noca, Koxopbie BMCCXB c KTOKHOH nacxbio neperopoflKH Hoca cocxasjiaiox ee noABH^CHyio nacxb. B saflHCM ox^ejie K xpamy HOCOBOH
neperopoflKH npHMbiKaex Kocxnaa nacxb neperopoflKH noca, npegcxaBJieHHaa HOcoBbiM rpe6HeM HeSnoro oxpocxKa BepxHen neniocxH, nepneH^HKyjiapHOH nnaCXHHKOH pemexqaxoH KOCXH H COUIHHKOM. SaflHHH Kpan couiHHKa orpaHHHHBaex
xoanti MeawajibHO. B Mecxax conpHKOCHOBCHHH xpameBoro H KOCXHOFO oxjjenoB
HepeflKO Ha6jnoflaK)xca H36bixoHHbie oSpasoBaHHa xpameBOH HUH KOCXHOH xKaHH, HXO oGycnoBJicHO HCpaBHOMepHHM pocxoM xpameBoro H KOCXHOFO CKenexa.
HexbipexyroJibHbiH xpam neperopo/iKH nepeflKO HCKPHBJICH, neMy cnocoGcxsyrox
pasHbie xeMObi pocxa xpama neperopo^KH H KOCXHHX CXCHOK HOJIOCXH noca. HcKpHBjieHHio HOCOBOH neperopoflKH xaKace cnoco6cxByK)x xpasMbi Hoca, paxnx,
HCKOxopbie 3H40KpHHHbie 3a6ojieBaHH«. ECJIH HCKpHBneHHe HOCOBOH neperopoaKH He Bbi3HBaex napyuieHHa HOCOBOTO flbixanna H csasaHHbix c 3XHM 3a6oneBaHHH, xaKoe cocxoaHHe HOCOBOH neperopoflKH HC asjiaexca naxojiorHeH H JienenHa
ne xpe6yex. ECJIH HOCOBOC Abixanne saxpyaneHo BCJieacxBHC ae^opMaiiHH HOCOBOH neperopoflKH, xo «HCKpHBneHHe HOCOBOH neperopoflKH» — sxo Anarnos, H
B03M03KHHM JieHeHHCM aBJiaexca xojibKO onepauna: yaajieHHe HCKpHBjieHHbix
ynacxKOB. KpoBOcna6»ceHHe CJIHSHCXOH neperopoflKH noca 6oraxoe, cocyaw
HMerox MHoroiHCJieHHbie aHacxoMOSbi (pHc. 9). B nepejjHeH xpexH neperopoflKH
Hoca pacnojiaraexca sona KncceJib6axa — cnjiexeHHe MCJIKHX apxepnoji, KanmmapoB H Benyji. HocKOJibKy cjiH3HCxaa, noKpbiBaromaa 3x0 cocyancxoe cruiexeHHe,
xoHKa, a GJTHSKOC pacnojioaceHHe K npejiaaepHio Hoca ne HCKJUonaer BOS-
II. KnMHHqecKaa aHaxoMMfl Hoca v\x naayx Hoca
37
MOHCHOCXb XpaBMbI, H3 COCyflOB 3OHbI
KHCcejn>6axa nacxo BO3HHKaiox HOCOBbie KpoBoxeneHHH. IlepeztHaa pemexnaxaa apxepna (a. ethmoidalis anterior)
BXO^HX B nonocxb Hoca nepes npOAwpaBJieHHyio njiacxHHKy, sa^Haa pemexnaxaa apxepna (a. ethmoidalis posterior) — nepes saflHee peuiexnaxoe
oxsepcxHe. 3a/jHHe ox^ejibi HOCOBOH
neperopoflKH KpoBOcna6»caeT neperopoflOHHaa BexBb KpbjjioHeSHOH apxepHH. OXXOK KPOBH ocymecxBJiaexca
HO O^HOHMCHHblM BCHaM.
Jlaxepajibnaa cxeHKa HOJIOCXH
Hoca ycxpoena Han6ojiee CJIO»CHO
(CM. pnc. 2 ripHJioaceHHa). KOCXHMH
CKCJICX
6OKOBOH
CXCHKH
Puc. 9. KpOBOCHa6*eHHe HOCOBOH
neperopoflKH:
1 — a. nasalis septi us a. sphenopalatina,
2 — IT. septi nasi ad a. ethmoidalis posterior,
3 — rr. septi nasi ad a. ethmoidalis anterior,
4 — plexus Kisselbachii, 5 — a. nasopalatina
HOJIOCXH
Hoca cocxaBjiarox: HpcoBaa Kocxb, sepxHHs nejiiocxb, cjieanaa Kocxb, peuiexnaxaa
Kocxt, HHHCHaa Hocoaaa paKOBHHa, BepxHKajibHaa njiacxHHKa He6noH KOCXH H
KpblJIOBH/lHblH OXpOCXOK KJlHHOBHflHOH KOCXH. Ha JiaxepaJIbHOH CX6HKC HMCIOXCa
xpn npOflOJibHbix Bbicxyna — HOCOBHC paKOBHHbl. Bepxnaa H cpe^naa HOCOBHC
paKOBHHbl npejjcxaBJiaiox co6oH Bbipocxbi peuiexHaxoH KOCXH, HH^cnaa HOCOBaa
paKOBHHa — caMOCxoaxejibHyro Kocxb. Ilofl KaxyjOH HOCOBOH paKOBHHoft pacnonaraexca oflHOHMCHHbiH HOCOBOH xofl. B CXCHKC HH5KHero HOCOBOPO xo^a, npnMepHO B 1 CM Ksa^H ox nepejjHero Konua HHHCHCH HOCOBOH paKOBHHbl, pacnojiaraexca oxBepcxne Hococjiesnoro Kanana. flpn pasBHXHH oxeKa CJIHSHCXOH HHacHCH HOCOBOH paKOBHHbl H HH^CHCrO HOCOBOTO XOfla OXBCpCXHC HOCOCJICSHOFO K3-
najia 6jioKHpyexca H BO3HHKaex cnesoxeneHHe, nanpHMep, nacxo MOXCHO naSjiioflaxb cjiesoxeneHHe npn ocxpOM HacMopKe. JlaxepanbHaa cxeHKa HH>KHero HOCOBoro xofla B HHJKHHX oxziejiax xoncxaa (HMCCX ry6qaxoe cxpoeHHe), 6jiHa<e K MCCry npHKpenjieHHa HH^HCH HOCOBOH paKOBHHbl SHannxeJibHO Hcxonnaexca, B CB«3H c SXHM nyHKUHK) BepxHCHejiiocxHOH nasyxH npOBO^ax HMCHHO Ha SXOM ynacxKC, oxcxynHB 2 CM ox nepe^Hero KOHua HH»cHeH HOCOBOH paKOBHHbl. JlaxepanbHaa cxeHKa cpe/iHero HOCOBOro xoaa npeflcxaBJiena HC xojibKO KOCXHHMH cxpynxypaMH, HO H aynjiHKaxypoH CJIHSHCXOH o6ojiOHKH B Mecxax BbiBO^Hbix oxsepCXHH npHflaxoHHbix nasyx noca, Koxopaa HOCHX HassaHHe <«J)OHxaHeJiJia» (HJIH
POJJHHHOK). ECJIH npHHOflHaxb cpeflHioio HocoByio paKOBHHy, nofl HCH oxKpoexca
nojiynyHHaa pacmejinna (hiatus semilunaris). Bxofl B nee cnepe^H H CHH3y orpaHHHCH KpIOHKOBHflHbIM OlpOCXKOM, C33JIH H CHH3y
KOCXHbIM Hy3bIpbKOM (bulla
ethmoidalis) peiuexnaxoH KOCXH. Knepean ox KproHKOBH^Horo oxpocxKa H Mecxa
npHKpenjieHHa cpejiHCH HOCOBOH paKOBHHbl na JiaxepajibHoii cxerace HMeexca eme
Bbicxyn — agger nasi. 3,uecb pacnojioKCHa nojiocxb, oxKptiBaiomaaca B Bopon-
38
TeMa II. HOC H OKOflOHOCOBblE HASVXH
Ky (infundibulum) — npocxpaHCTBO Meacfly JiaxepanbHOH no-
II. K/iHHHHecKaa aHaroMMfl Hoca M npMflaTOHHbix naayx noca
39
TaKHM o6pa30M, CXCMaXHHCCKH HOCOByK) HOJlOCXb MO*HO HpCACXaBHXb B BH-
pOCTKa, MCflHaJIbHOH CTCHKOH Op-
Zie CHcxeMbi Hepeayiomnxca KanajiOB c no^BH^KHbiMH H pHrH/jHbiMH cxeHKaMH H
CHCXCMOH HepeayiomHxca cyaceHHH H pacuiHpeHHH. riepeHHCJieHHbie oco6eHHOCXH anaxoMKHecKoro cxpoeHHa OKa3biBaiox cymecxBCHHoe BiiHflHHe na aapoflH-
6HTbI (GyMaxCHOH lUiaCXHHKOH) H
H3MHKy B HOCOBOH HOJ1OCXH H HFpaK)X HCKJHOHHXenbHO Ba>KHyK» pOJlb B peajlH33-
MeflHaJIbHOH CTCHKOH BepXHCHe-
UHH OflHOH H3 BaTKHCHUlHX (J)yHKUHH HOCa
BCpXHOCTbK) KpKJHKOBHflHOrO OT-
JIIOCTHOH nasyxH. B BoponKy oxKpbmaioTCH ecxecxSeHHbie coyc-
AblXaxejIbHOft.
AH3TOMHMCCKHC OCoBcilIIOCTH HOJIOCTH HOC3 HOBOpO/K/jeHIIl.IX. FlpH pO>K-
pe6eHOK npHcnoco6neH xonbKO K nocoBOMy awxaHHio. IloJiHaa o6xypaHOCOBblX XO^OB y HOBOpOKfleHHWX ^CXCH HCCOBMCCXHMa C )KH3HbK), HO3XO-
nasyx. Ha npoxa>KeHHH
HocoBoro xo/ia oxKpbiBaroxca nepe^HHe H cpe^HHe KJiexKH peiiiexPuc. 10. CicejieT HOCOBOH HOJIOCTH
naxoH nasyxH. B BepxHHH HOCOBOH xofl oxKpHBaioxca 3aflHHe
aneHKH pemexnaxoH KOCXH. HanGonee HaraaflHO cooGmemie OKOJiOHOCOBbix nasyx c
nonocxbK) Hoca npeacxaBneHO na pnc. 10.
AnaxoMKHecKyio o6nacxb, o6te,ziHHaioiH,yK) nepeAHHH KOHCU cpeAHeft HOCOBOH paKOBHHbi, KpKDHKOBHflHbiH oxpocxoK, KJiexKH agger nasi, nonynyHHyio
peiuexHaxyio 6yjijiy, HaswBaiox ocxHO-MeaxanbHbiM KOMnjteKCOM. 3xo
; y3Koe Mecxo cpeflHero HOCOBOFO xoaa. UlnpHHa ero ne npeBbimaex neCKOJlbKHX MHJlUHMeXpOB.
CornacHO coBpeMCHHoft KOHUCHUHH, paspaSoxaHHon B KOHUB 60-x rbflos
npo^eccopoM B. MeccepKUHHrepoM (Ascxpna), B OCHOBC 6onbiuHHCXBa sa6oneBaHHH OKOJiOHOCOBbix nasyx Jiexcax napymeHHa BCHXHJMUHH H flpenasKa o6jiacxn
ocxHO-MeaxajibHoro KOMHJieKca.
Hacxb noJiocxH noca, pacnojiO5KeHHaa HTOKC yposHa Hrafcnero Kpaa cpe/mnx HOCGBbix paKOBHH, HasbiBaexca ^wxaxejibHOH oSjiacxbK), a npocxpancxBO Bbiuie yposHa
HroKHero Kpaa cpe^Hnx HocoBbix paKOBHH — o6oHaxejo>HOH o6jiacxtio. flfix pecnnpaxopHoro oxaena CJIHSHCXOH o6ojio4KH xapaKxepna Gojibiuaa xoinnHHa CHHSHCXOH
o6ojiOHKH. 3nHxejiHH flbrxaxejibHOH o6jiacxH — MHoropa^HbiH MepuaxejibHUH UHJiHHWpHHecKHH. B noASHHxejiHajibHOM oxaejie coflep»caxca MHoroHHCJieHHbie anbseonapHO-xpy6Haxbie >Kejie3bi, Koxopue no xapaicxepy ceKpexa ^ejiax na cjiHsncxbie,
ceposHbie H CMeiuaHHbie. Jlflu pecnnpaxopHOH lacxn CJIHSHCXOH 060x101101 xapaKxepno najiHHHe B ee xojime nemepHcxbix BCHOSHbix cnjiexeHHH —
pacuiHpeHHbix BCHOSHbix BJiarajiHui, HMeiomnx MbimcHHyio cxeHKy, 6naroflap« <
OHH Moryx coKpamaxbca B oGteMC. KaBepHosnaa XKam> coflepacnxca B xojime CJIHSHCXOH 06OJIOHKH HH>KHHX HOCOBblX paKOBHH, HO HHJKHeMy KpaKD CpeflHCH HOCOBOH paKOBHHbi, B saflHHx oxflenax HJDKHCH H cpe^neH HOCOBOH paKOBHH. FlemepHCXbie BCHOSHbie cnjiexeHHH o6ecneHHBarox peryraujao xeMnepaxypu sos/iyxa, npoxoflamero
HCpes nojiocxb Hoca (CM. pnc. 3 FIpHJKmeHHa). B oGonaxejibHOH oGnacxn KpOMe cneUHiJiHMecKoro o6oHaxejibHoro annxejina HMeioxca onopnbie UHnHHapHHecKHe KJICXKH
H )Keae3bi, BbipaSaxbiBaiomHe HOWKHH ceKpex.
My aHaxoMHHecKaa cxpyKxypa HOCOBOH HOJIOCXH HOBOpo>KfleHHbix HMeex ocoSCHHOCXH, npeaoxBpaujaiomHe nonHyjo oScxpyKunio HOCOBBIX XOSOB npn naCMOpKe, cpbirHBaHHH, anjieprHMecKHX peaKHHax H x. a. IlponopuHH xena HenoBeKa npn poayieHHH SHaHHxenbHO oxjiHHaioxca ox BCCX jjpyrax Bospacxnbix nepnoflOB 5KH3HH HMCHHO 6ojIbIHHM pa3MCpOM KpaHHaJIbHOFO OX^ejia. Ilo 3XHM npHHHH3M CpaBHHBaXb HOJlOCXb HOCa HOBOpOHC^eHHOro C HOJlOCXbK) HOCa BSpOCJIOFO
HenoBeKa HeJibss. Y HOBopwfmeHHbix B HOCOBOH nonocxn npeo6naflaex nonepeiHbifi pasMep. XoaHbi HOBOpoxyjeHHoro B nonepeiHOM CCHCHHH HanoMHHaiox
«jie*amHe oeajibi», xoraa KaK y Bspocjiwx Jiro^eH xoanbi Bbirnaa«T KaK «cxo«mHe
OBanbi». HHHCHHH HOCOBOH xoa oxcyxcxsyex, HocoBaa paKOBHHa JICHCHX Ha ane
HOJIOCXH Hoca. Bepxnaa nocoBaa paKOBHHa eme ne pasBHxa. Cpe^naa nocoBaa
paKOBHHa KOpoxKaa, ee nepeaHHH KOHCU aajibiue OXCXOHX ox nepeannx HOCOBMX
oxsepcxHH, qeM KOHBLI HH»HCH HOCOBOH paKOBHHbi. Flpn xaKOM BHyxpeHHCM
cxpoeHHH nonocxH Hoca o6mHH H cpe^HHH HocoBbie xoflbi mnpoKHe. CjiHSHCxaa
o6ojiOHKa Hoca rpy^Hbix ^exeft cioioHHa K pasBHXHio oxexa, OflH3KO H B 3XOM
cjiynae HOCOBOC auxamie nojinocxbio He 6;ioKHpyexcs.
KpOBOCHa6»eHHe HOJIOCXH noca ocymecxBJiaexca H3 CHCXCMU Hapy^KHoii H
BHyrpeHHCH COHHUX apxepnH. Hs Hapy>KHOH COHHOH apxepnn 6epex CBOC Hanano
ocHOBHoneGHaa apxepna. Ona BXOAHX B nojiocxb Hoca nepea ocHOBHOHeGnoe oxBepcxne (foramen sphenopalstinum) H o6ecneiHBaex KpOBOCHa6»eHHe 3a^HHX H
HH>KHHX OXACXIOB nonocxH Hoca. 3xo OCHOBHOH cocya, nnxaioiUHH nojiocxb noca.
Hs BHyxpeHHeft COHHOH apxepHH 6epex Haqajio raasHHHHaa apxepna (a. ophtalmica), ox Koxopon oxxo^six BCXBH aepeOTeft H sa^HeH pemexHaxoH ..apiepHH, STH
apxepHH oGecneHHBaiox nnxaHne BepxHHx oxflenoB nonocxH noca. Taicace B KpoBocHa6>KeHHH nonocxH Hoca ynacxByiox BCXBH nHueBofi H Hoco-He6noH apxepHH.
JlHM(})axHHecKHe cocyflbi oSpasyiox ^Be CCXH: noBepxHOCXHyio H rny6oKyio.
JlHM(J)axHHecKHe cocy^bi abixaxeubHOH H oGonaxenbHOH o6nacxeH, necMOxpa na
oxHocHxejibHyro pa3o6meHHOCxb, HMCIOX anacxoMosbi, H JIHM^OOXXOK npOHCXoflHX B oflHH H xe >Ke flHM({)axHHecKHe ysjibi: ox nepeflHHX oxjiejioB DOJIOCXH HOca — B noflHenrocxHbie, ox sa^HHx OXJICJIOB — B rny6oKHe uienHbie.
HyBCXBHxenbHyK) HHHepBaiiHio nonocxn noca oSecnenHBaex nepsaa H Bxopaa
aexBb xpoHHHHHoro HepBa. IlepeflHHH oxflen HOJIOCXH noca HHHepBHpyexca I sexBbio xpoHHHiiHoro HepBa (nepe,uHHH pemexnaxbiH nepa — BexBb HOCOPCCHHHHO-
40
Teivia II. HOC H OKOJlOHOCOBblE FIASYXH
ro nepBa). HocopecHHHHblH nepB H3 OOJIOCXH noca npoHHKaex Hepes HocopecHHHHOC oxsepCTHe B nonocTb Hepena, a oxxyaa — Hepes peuiexnaxyio ruiacxHHKy
B HocoByK) nojiocxb, rfle H passexsjiaexca B oSnacxH neperopoAKH Hoca H nepeaHHX oxflejiOB jiaxepanbHOH CXCHKH HOJIOCXH noca. Ero Hapyacnaa Hocoaaa sexBb
BbixoflHx na cnHHKy noca Mexyiy HOCOBOH Kocxbio H BepxHHM jiaxepajibHWM
xpamoM, HHHepBHpya Ko»cy napyHCHoro noca. 3a£Hne oxflejibi HOJIOCXH Hoca HHnepBHpyioxca Bxopoft BexBbio xpOHHHHHoro HepBa, npOHHKaiomeH B nonocxb HOca nepes sa/iHee peuiexnaxoe oxBepcxne. B^ojib neperopoflKH noca B nanpaBJieHHH caa^H nanepefl H,nex Kpynnaa sexBb — HocoHe6HbiH HepB. B nepeflHCM oxflejie OH npoHHKaex nepes pesupBbiH Kanaji B oiHSHCxyio o6ojiOHKy xsepfloro He6a, rfle anacxoMOSHpyex c HOCOBHMH BexaaMH ajibBeojiapHbix oxpocxKOB H ne6Horo Hepsa. CeKpexopnaa H cocyAHcxaa HHHepBauna ocymecxBJiaexca ox sepxnero uieHHoro CHMnaxHHecKoro ysjia, nocxranrjiHOHapHbie BOJiOKna Koxoporo
npoHHKaiox B nonocxb noca B cocxaBe Bxopoft BCXBH xpOHHHHHoro HepBa. IlapacHMnaxHnecKaa HHHepBauHa ocymecxBJiaexca nepes KpbinoHeGHbiH ysen sa cnex
nepsa KpbmoBHflHoro Kanajia. 3xox neps oGpasosaH CHMnatHnecKHM nepBOM,
oxxoflamHM ox Bepxnero uieHHoro CHMnaxHHecKoro ysna H napacHMnaxHHecKHM
HepsoM, 6epymHM Hanano ox KOJieHnaxoro ysiia jiHueBoro HepBa.
Ilpn;iaTolinbie nasyxu noca. K OKonoHOCOBbiM nasyxaM noca oxHOcax BOSnonocxH, OKpyjKaromHe nojiocxb Hoca H coo6maK>m,Heca c He^ c IIOMOoxBepcxHH (BbiBoaHbix npoxoKOB). PasjiHHaiox BepxHeneJiiocxHyio, noSnyio",
peuiexMaxyK), KjiHHOBHflHyK) nasyxH. Bee OKOJioHOcoBbie nasyxH napnbie. PasMepw npHAaxoHHbix nasyx noca (HUH) y pasnux Jno^eH neoAHHaKOBbie, HO cHHxaexca, HXO HanGojibiuHH o6ieM HMCCX BepxHenejirocxHaa nasyxa (ox 5 ao 30 CM3).
^. BepxgeHejirocTHaa nasyxa (sinus maxillaris, sin. Highmori, raiiMOpoBa naayxa) pacnojiaraexca B xene eepXHCH HCJIIOCXH. Ho 4>opMe ona HanoMHHaer nenpaBHjibHyio HexbipexrpaHHyio nHpaMHfly, ocnoBaHHe KOTopoii o6pameno K IIOJIOCXH
Hoca. ^ngpanmojo cxenKy BepxHenejiiocxHOH nasyxH oSpasyex jiHueaas cxeHKa
xejia BepxHefi HCJHOCXH. B Heii HMeexca yrjiyGjiCHHe — «co6anba aMKa», r^e
Kocxb nanGojiee HcxoHneHa. B 3XOM Mecxe npoBO^HT BCRpbixne BepXHeHejiiocxHOH nasyxH. Bepjujaa'CTeHKa — raasHHHHaa, rpaHHHHx c op6HTOH. 3xa cxeHKa
HanSo^ee xoHKaa, HepeflKO B Heii HMeioxca /mracueHUHH. B 3x08 CXCHKC npoxo4Hx canalis infraorbitalis, B KOXOPOM pacnojiaraexca oflHOHMCHHbiH Heps H cocy«bi. B MCAHajibHbix oxae^ax Bepxnaa cxeHKa nasyxH npHMblKaex K CJICSHOH KOCXOHKC H oGpasyex Bepxnee oxsepcxHe nococjiesHoro KaHajia. flgojiasyxH — ajibseojiapHbiH oxpocTOK BepxHefi HeJiiocxH. B pa.ae cjiynaes KopHrt sy6oB (3-6) Bbicxoax B npocBex naayxn, HXO o6ecnenHBaex pa/j oco6eHHOcxeii xeieHHa BocnajinxejibHoro npouecca: BOSMO>KHO pasBHxne oflonxoreHHoro BocnaneHHa raiiMOpoBOH nasyxH, npn HJiOM6HpoBaHHH sy6nbix KanajioB BOSMTOKHO npOHHKHOBCHHe
mioMSHpOBOHHoro MaxepHajia B npocsex nasyxw, nocne 3KcrpaKUHH sy6a HMeioxca npeflnocbiJiKH (JjopMHpOBaHHa CBHuja Mexay'raHMOpoBOH nasyxoii H JiynKOH sy6a. BepxyuiKa nnpaMMflbi HanpaBJiena K BepxHenejiiocxHOMy 6yrpy H rpa-
II. KnuHHMecKaa anaxoMi/ia Hoca v\x naayx noca
41
HHHHX c KpbiJiOHe6HOH aMKoft. MeflMJibHaa^cxeH^ajjasyxH (ocnoBaHHe
Abi) — Jiaxepajibnaa cxenKa DOJIOCXH Hoca. B HHMCHCM ox^ejie 3xa cxeHKa HaH6ojiee xoncxaa, nocxeneHHO Hcxonnaexca no HanpaBneHHK) K Mecxy npHKpenjieHHa
HH5KHCH HOCOBOH paKOBHHbl, a B oGjiaCXH CpeflHCFO HOCOBOFO XOfla HMCCX flHFHC-
UCHUHH, npHKpbiibie flynjiHKaxypOH CJIHSHCXOH o6ojiOHKH. Ilo OXHOUICHHIO K nasyxe ee BbiBOflHoe oxsepcxne Haxoflnxca Ha Me/jHajibHOH cxenKe npaKXHnecKH y
BepxHero Kpaa, B cBaan c HCM npn SKCcy^axHEHOM BocnajiHxenbHOM npouecce
OXXOK oxflenaeMoro HS nasyxn saxpyflHen. OXXOK yjiyniuaexca npH nepeMene norojiOBW, Kor^a BbiBoanoe OTBCpcxHe nasyxn nepeBOflHxca B KHMCHCC
C SXHM csasana oco6eHHOCXb SoneBoro CHH^pOMa npH FHOHHOM
BOcnaneHHH raHMOpOBofi naayxn: ycaneHHe FOJIOBHOH 6onH B BenepuHe
yjiynmeHHC cocxoaHHfl B yxpeHHHe nacbi.
B pajie cnynaCB B cpeaneM HOCOBOM xo/ie HMeexca flononHHxeJibHoe
HOC oxBepcxne nasyxn. HanHHHC aonojiHHxenbHoro coycrba napyuiaex
HbiB OTXOK oGpasyiomefica B nasyxe CJIHSH, HXO cnoco6cxByex passHXHio xpoHHnecKoro BocnajieHHa, o6pa3OBaHHio xoanajibHbix nojinnoB. Sa^He-BepxHHe ox^ejiw nasyxH HenocpeACxseHHO rpaHHHax c rpynnofi saflHHX KJICXOK pemexnaxoro
Jia6HpHHXa H KJIHHOBHflHOH HaSyXOH, B CBaSH C MCM XHpyprHHCCKHH flOCXyn K
SXHM o6nacxaM BOSMOxceH nepes BepxHeHejnocxHyio nasyxy.
^ JIo6naa nasyxajsinus frontalis) pacnojiaraexca B neuiye JioGnoH KOCXH H »Bjiaexca caMOH BapwaSejibHOH no pasMepy H (J>opMe OKOJIOHOCOBOH nasyxofi. Hepe^Ko na6nioflaexca ee nojmoe oxcyxcxBne (arenesna) — name o^HOCxopOHHee.
Flpasaa H Jiesaa JioSnbie nasyxn Moryx snanHxejibHO pasjinnaxtca no oGieMy, KOraa Ha6jnoaaexca HCflOpasBHXHe OAHOH HS nasyx — rnnoreHesHa. Ilasyxa Moacex
HMexb nepeMbiHKH. PasMep nasyxH sasHCHX ox cxeneHH pesopGuHH nemyH Jio6HOH KOCXH, B pe^KHX cjiyHaax ^ocxHraa jioSnoro 6yrpa HJIH pacnpocxpanaacb sa
nero. Ilasyxa HMCCX nepeflnioio, sa^Hioio, HHHCHIOIO H Me^HajibHyio CXCHKH. IlepeflHaa H sa^Haa CXCHKH, cMbixaacb, o6pasyioT JTOJI. /JTegeaHaa^cxeHKa npeacxaBJieHa ryGnaxoH (flHnjiosxHHecKOH) Kocxbio XOJIUIHHOH ox 1 30 8 MM. HaHGonbiiiaa xojiuiHHa SXOH cxeHKH HaGjuoaaexca B o6jiacxH Hafl6poBHbix pyr. 3aanaa cxeHKa^io6HOH nasyxn (lamina ytrea) o^HOBpeMCHHO «BJiaexca
/>2xeHTcoH nepeaneH HepenHoft KMKH, HenocpeacxBCHHO HPHJIOKHX K nepeflHefi
jie roJiOBHoro Mosra. TojimjiHa saflnefi CXCHKH Koppejinpyex c pasMepoM
nasyxH: HCM MCHbiue o6teM naayxn, XCM xonme ee sa/inaa cxeHKa.
£xejHKa (OTO nasyxH) B narepajibHOM oxflejie rpaHHHHx c opGnxofi, B
HOM — c nojiocxbio Hoca. B 3XOH o6nacxH Kocxnaa xKaHb HMeex aneHcxoe cxpoeHHC BCJie^CXBHe BHCflpCHHa KJI6XOK peUICXHaxOH KOCXH. OxBepCXHB BblBOaHOFO
KaHajia jioSnoH nasyxH naxoflnxca B ee HHHCHe-MeflHajibHOM yrjiy na yposne ana.
HpH ero o6cxpyKUHH (HanpHMep, ns-sa oxeKa) flpena>K nasyxn npeKpamaexca, H
oSpasyeMHH ceKpex HaKanjiHBaexca B HOJIOCXH. CKaruiHBaHHe 3Kccy/iaxa npHBO/inx
K jjaBJieHHK) Ha Kocxnbie CXCHKH, B oxflejibHbix cjiynaax — K pasBHxnio ocxeoMHeCXCHKH nasyxH. TaKHM oGpasoM, cosaaioxca ycjiosna fljia npOHHKHO-
42
Teiua II. HOC H OKOJIOHOCOBblE RA3YXM
BCHHH HH(J>eKHHH B HOJIOCXb HCpCna KOHTaKTHbIM IXyXCM. QiaBJieHHC OKOHHaHHH
xpoHHHHHoro HepBa HaKaruiHBaiomHMCH B iiasyxe 3KccynaxoM BbBbisaer BbipaiH 6oneBoii cHH^pOM. OxcyrcTBHe flpcnaxa o6i>acHaex nocxoancxBO omyronoBHoii 6onH. MeAnanbHaa cxeHKa — MeHcnasyuinas neperopo/ZKa. Ee
saBHCHX ox nneBMaxHsaqHH nasyx. PacnojioHcena neperopo^Ka carnxno cpe/xneH JIHHHH, HO nepeziKO Ha6jiK>;jaexca ee oxioiOHCHHe: B cpe^neM
ox/jejie neperopo/iKH Jio6Hbie nasyxn nacxo cooSmaioxca Meamy coGoft.
igJTasyxH pemexnaxoH KOCXH, (sinus ethmoidales) cocxoax HS ox^enbHbix KJieXOK, coo6maiomHxca Meamy co6oH. KOJIHHCCXBO KJICXOK — ox 5 ,50 12 H 6ojiee.
Pacnojiaraacb B xoume pemexHaxoB KOCXH, KJICXKH pemexnaxoro JiaGnpHnxa rpaHHHax: CBepxy — c jio6HOH nasyxon H nepeflHefi nepenHOH SMKOH, csa^H — c
II. KnuHnsecKaa aHaxoMna Hoca M npnaaxoHHbix naayx Hoca
43
BeHosnaa cncxcMa HMCCX MHoroHHCueHHbie anacxoMOSbi c BenaMH
nonocxH Hoca H nepena. BCHH BepxHeneinocxHOH nasyxn XCCHO anacxoMosHpyiox c senaMH nHua, BenaMH KUHHOBHJIHOH nasyxn, KpbinoBHflHbiM cnnexeHHCM, FJiaSHOH B6HOH, B6HO3HbIM CnneXCHHCM XBepflOH MO3FOBOH o6oHOHKH.
HMCIOXCH BenoSHbie aHacxoMO3bi Me^K/iy OXBOAHIUHMH cocy^aMH no6HOH na3yXH,
^POHTO'OP^HXajlbHblMH
KJlCXKaMH
peUICXHaXOH
na3yXH.
HaCXHHHO
KpoBb H3 BCH peiiiexHaxoFO JiaSnpHHxa HMCCX OXXOK B BBHW rjiasHHuw H nemepHcxbifi CHHyc. OnHcanw anacxoMOSbi BCH KJIHHOBH^HOH nasyxn c BCHOSHHMH cnjiexeHHHMH HocoFJioxKH H nemepHCxoro CHHyca. HeoGxo/niMo OXMCxHXb, HXO JiHM<})axHHecKaa cncxeMa BCBX npnflaxoHHbix nasyx Hoca anacxoMOsnpyex MOK/iy co6ofi H HMeex xecnyio CBKSL c cy6apaxHOHflajibHHM npo-
KJIHHOBHflHOH nasyXOH, JiaxepaJlbHO - C MCflHaJIbHOH CX6HKOH rJiaSHHqbl H
CXpaHCXBOM FOJ10BHOFO MO3F3.
BepxHenejiKtcxHOH nasyxoH. MeflHanbHaa cxeHKa pemexnaxoH nasyxH aBJiaexca
JiaxepanbHOH cxeHKofl nonocxn Hoca Bbiiiie HH5KH6H HOCOBOH paKOBHHH. B 33BHCHMOCXH o'x pacnoJioKCHHa BbmejMiox nepejjHHe, cpe^HHe H sa^HHe rpynnw KJICXOK pemexnaxoH KOCXH. Hepe/iHHe H cpe^nne KJICXKH oxKpbiBaroxca B cpe^HHH
TaKHM o6paaoM, 6jiH3Koe COCC^CXBO H HanHnne oGmnx CXCHOK, o6uiHpHaa
cexb anacxoMOSHpyiomHX cocyflOB onpeaejiarox MexannsM pasBHxna BHyxpHHepenHbix ocuoacHCHKH npn BOcnaneHHH npnaaxoHHbix nasyx Hoca.
B npoaecce pocxa pe6eHKa npH^axonHbie nasyxn noca npexepneaaiox 3HaHHxenbHbie H3MeneHHfl (CM. xaSji. 1).
HOCOBOH XOfl, 3aflHHC KJ1CXKH - B BepXHHH HOCOBOH XOfl.
» KjiHHOBHiiHaa naayxaj'sinus sphenoidalis) pacnojiaraexca B xene KJIHHOBH/IHOH KOCXH. Ilaayxa pasAenena neperopoflKOH na ^BC nonocxn, Kaxyjaa H3 KOXOpwx HMCCX CBoe BbiBoanoe oxBepcxne, oxxpHBaiomeeca B c(J)eH03XMOH^ajibHOe
npocxpancxBO BepxHHx HOCOBHX XOAOB. BbiBO^Hoe oxBepcxne pacnojiaraexca B
BepxHCMe^HajibHOM oxflejie nepeaneH CXCHKH nasyxH. Be£XHa»^cxeHKa nasyxn
rpaHHHHX co cpeaHCH HepennoH SMKOH H rHno({)H3OM. BoKOBbie CXBHKH i-paHHnax
co spnxeJibHbiM HepsoM, c BHyxpeHHCH COHHOH apxepHeSTnemepHCXbiM cnnycoM,
B CB83H c IBM naTonorHHecKHH npouecc Moxcex pacnpocxpaHHXbCfl B nonocxb HCpena. Opn BocnaJinxejibHOM npou,ecce B KJiHHOBHflHOH nasyxe Moryx naGjnoflaxbca spHxenbHbie HapyuieHHa, xax KaK CXCHKH naayxH XOHKH (1-2 MM) H B HHX HCpeflKO HMeroxca AHrncueHUHH. HHacnaa cxeHKa naayxn oGpasyex nacxHino Kpwmy nonocxH noca B sa/ineM oxflelier5acxHHHb — Kpbimy HOCOFJIOXKH. 3xa cxeHKa
) xonmnny — 10-12 MM, COCTOHX H3 ry6HaxoH KOCXH.
npn/iaxKaMH nonocxn noca, npHflaxonnbie nasyxn csasaHbi HC xonbKO anaxoMO-xonorpa<j)HHecKH, HO H 4>yHKUHOHajibHO. O6mnocxb oGycjioBJiena
CflHHOH CHCTCMOH KpOBOCHa6»CeHHa, B6HO3HOrO H JIHM^aXHHCCKOrO OXXOK3, HH-
HepBau,HH H anajiorHHHbiM cxpoeHHCM CJIHSHCXOH o6o;iOHKH.
BacKynapHsauHH npHAaxo^Hbix nasyx Hoca oienb 6oraxa H npe^cxaBJieHa
apxepHajibHbiMH BexBaMH, xecno anacxoMOSHpyromnMH Mexc^y co6oB. BepxHeneniocxHyio nasyxy cnaGxcaex Kposbio BHyxpeHHaa nenrocTHaa apxepna.
OcoSeHHO Soraxo cna6>Kaexca Kposbio MeflHanbnaa cxeHKa. PeuiexnaxbiH naGnpHHX nnxaexca H3 CHCXCMH cocy/iOB CJIHSHCXOM o6o:ioHKH HOCOBHX paKOBHH H pemexnaTbix apxepHH, noGnaa nasyxa KpOBOCHa6>Kaexca HS apxepHH
HOCOBOH nojiocxH H BexBeft rjiasHHHHOH apxepHH. OcHOBHaa nasyxa nonynaex
KpOBb H3 apxepHH HOCOBOH nOJIOCXH H apxepHH XBCpflOH MOBFOBOH
Pa3BHTHe iipHaaTOMHbix nasvx Hoca (no M. ft. Kosjiosy, 1985)
BO3MO)K-
Flaayxa
HOBOpO)KfleHHbIH
POCT B aercKOM eospacre
Hocrb pemrreno-jiorHnecKoro HCcjieaoBanHs
SasepnieHHe
paSBHTHS
BepxHene- B <J)opMe yanH- B nepBbie rogbi — pocx MejuieH- B 1-H rofl B ISjier
JKH3HH
H6HHOH
SMKH Hbift: 2-3 MM 33 1 rofl.
nasyxH
BejlHHHHOH
B 3 ro^a — 23 x 12 x 13 MM
3 x 4 x 7 MM
SHaiHTenbHbiH peer nocne npo-
JIIOCTHbie
pe3bIB3HHH nOCXCWHHblX 3y6oB, B
8 nex — 28 x 20 x 23 MM
PemexHa- HajIH4H6
RO 5 J1CX
B03HHKHO-BCHHe HO- Bo 2-H rofl B 12-13 Jiex
xbie nasy- OBajibHtix sne- BWX aqeeKj aanbHeHiUHH pocx >KH3HH
XH
6K B6JIHMHHOH
cBssan c yBejiHHCHHCM o6ieMa B
2 x 3 x 2,5 MM pesynbxaxe ocxeonjiacxHnecKHx
npoueccoB B KOCTH
KJIHHO- ^ ITyswpeK naay- HanHHaa c 5 JICT — oxneTJiHBHH B 6-7 Jiex B 12-15jiex
BHflHbie
°j XH
nasyxH
\e
2 X 2 X 1,5 MM
HMeerca HOCO- Ha 2-3 rofl peiuexnaxwe KJICXKH C 7-H Jiex
jioGnoe
conpHKacawxcs c no6HOH KOyrnyGjieHHe
cxbio, ao 6 jiex sanaxoK nasyxH
pyflHMeH-TapHWH. C 7jiex —
MeAJieHHHH poor jioGnoH nasyxH
nasyxH
POCX B KJIHHOBHflHOH KOCXH
B 20 Jiex
44
Tewa II. HOC M OKOJIOHOCOBblE HASYXM
y HOBOpoayjeHHoro BepxHe^eniocxHaa nasyxa npeacxaBnaex co6oH ysKoe
npocxpancxBO, c>Kaxoe HapyacHofi CXCHKOH HOJIOCXH Hoca, rnasHHueft H 3anaxKaMH
B. EpH 3XOM oSnapyacHBaioxca SHanHxenbHwe HitaHBH^yajibHbie paajiHHua B
H 4>opMe nasyxH. KaK npaBiuio, y HOBOposKfleHHbix H rpyaubix flerefi nepasMep nasyxn npeBbiuiaex ee pasMepu B iimpHHy H Bbicoxy. y HOBopo>K#eHHoro o6i>eM nasyxn B cpe^HCM cocxasjiaex 0,15 CM3, a K 2-M ro^aM —
1,5 CM3. K Bospacxy 2-2,5 rofla npo^oJitHbiH pasMep yBCJiHMHBaexca no 1 CM, a
Bbicoxa — JK> 1,2 CM, 3HaHMxenbHbie oco6enHOCXH npeAcxaBJiaiox H CXCHKH nasyxn:
BHyrpeHHaa cxeHKa aBJiaexca AyruiHKaxypoH CJIHSHCXOH oGonoHKH H cooTBercxByex, Kan npaBHJio, cpe^HeMy HocosoMy xoay. HH>KHaa HocoBaa paKOBHHa pacnono5Kena HH»ce ocHOsaHHa BHyrpeHHeB CXCHKH nasyxn. IlepeAHaa H HH^cnaa CXCHKH — OHCHb ysKHe, npH 3XOM K HH^cHeH cxeHKe Hcnocpe/icxBeHHO npHMWKaiox
aneHKH sy6oB, H xoubKo c 4-5-n Jier HanHHaerca HHxeHCHBHbiH pocx nasyxn sa
ciex anbBeojiapHoro icpaa H ocBo6o>KfleHHa ox sySHbix MCLUOHKOB. K 6-H rojiaM nasyxa no <})OpMe HanoMHHaex nasyxy Bspocjioro, K 8-H roziaM ^HO nasyxH onycKaexca AO /jna nojiocxH noca, nojinoro pasBHXHa naayxa flocxnraex K 12-14-H ro^aM. y
peiiieTHaxaa nasyxa npe/icxaBJieHa OBajibHHMH aneHKaMH BCJIH2 x 3 x 2,5 MM. HanSojiee HHxeHCHBHbiH pocx KJICXOK pemeTiaxoro Jia6HpHHxa oxMeiaexca B nepsbie ro^bi >KHSHH pe6eHKa. K 5-6-My ro^y XHSHH KJICXKH
nojiHocxbio c<j>opMHpoBaHbi, HX pocx npofloiwfaexca sa cnex oGpasosaHHa
6yxx H HCXOHHCHHa KOCXHHX nepeMbineK. PasBHXHe KJICXOK pemexHaxoro naGnpHHxa aaKaHHHBaexca K 12-14-H rojiaM.
JloSnaa nasyxa y HOBOpoayieHHoro oxcyxcxByex, HMeexca xojibKo nocojio6HOC yrjiy6neHHe, Koxopoe ao 5 -6-H jiex yBejiHHHBaexca HesHainxejibHO. JloSnaa
nasyxa pacxex MCfljieHHO, sasepuiaa CBOC paaBHxne xojibKo K 19-25-H ro^aM.
OcHOBHaa nasyxa y HOBOpoacaeHHoro HMeex BHA menH ao 2 MM flnnnbi. CBOCH
KOH(j)HrypaiiHH ona flocxnraex K 12-14-H
Bonpocbi MTorosoro KOHTponn 3H3HMM no rewe II
1. KaKOBbi dpn3MonoraMecKne dpyHKUMM nonoc™ Hoca H
nasyx Hoca?
2. KaKan apiepna o6ecneHMBaer KpoBOCHa6>KeH
nonocTM Hoca?
3. KaKMe aHaxoMnnecKMe o6pa3OBaHnn oGpasytor
4. flOHewy motiHbie 3a6oneBaHMfl Hapy>KHoro noca Moryr npHsecxn K
BHyrpuMepenHbix ocnoKHeHMii?
5. FlepeHMcnuTe npuflaroMHbie nasyxH Hoca, coyciba Koropbix OTKpblBaiOTCfl B CpeflHMM HOCOBOM XOfl.
6. B SaccefiHbi KBKMX BGH ocymecTBJineTca BenosHbiM OTTOK us nonocxn Hoca?
7. KaKOBo d3H3nonornHecKoe 3HaneHne Hocosoro Knanana?
8. KaKMM o6pasoM ocymecxB^nexcfi samynHaa cpyHKqua nonocru Hoca?
II. KnuHnneCKaa aHaxoMna Hoca n npMflaroHHbix naayx Hoca
9. MTO osHanaei xepwuH «KOHflnqMOHMpoBaHne BO3flyxa»? KaKMM 06pasoM ocymecTBnaexcsi KOHflnqnoHnpoBaHne eosflyxa B nonocxn noca?
flononHumenbHbie eonpocbi dnn neduampu'-iecKoao (paKynbmema:
10. KaKOBbi aHaxoMMMecKne oco6eHHOCTM nonocxn Hoca HOBOpo>KfleH1 1 . KaKOBbi oco6eHHocxn TonorpadDnn npuqaxoHHbix nasyx Hoca y
pe6eHKa?
45
I. KnuHMsecKaa
moTKM
47
— us Kypca ronorpacpMHecKOM aHaroMMM — KneTMaroMHbie npocrpaHCTBa men;
— us Kypca rucTonorun — runbi TKaneii, BxoflHainx B cocras MUHflanun rnoTOHHoro Konbqa.
OcHaujeHue. OcseTMTenbHbie npn6opbi: MCTOMHUK ceera, no6Hbiti pecf)neKTop, orocKon, napMHrocKon, BO/iOKOHHaa oniMKa.
Ha6op MHcrpyweHTOB. Hocosbie sepKana, ujnaienn, yiuHbie BOPOHKM, ropraHHbie M HocornoTOMHbie sepKana, sonflbi naBMBHbie, nunqeTbi yiiiHbie, nnHqeibi
HOCOBbie.
eiua III.
MOTKA
Pa6onee MGCTO. MHCTpyMeHTanbHbiw CTOJIMK, HacronbHan JiaMna, cnnproBKa, flsa ciyna.
Mecjo npoeefleHMH aaHnrnn. YMeSHaa KOMnaia, otfleneHkie
Bpeivm aaHHTHfl — 180
ronomn.
LJe/ib aatttmifl. Ha ocHoeaHnn SHSHMM HopwanbHofi v\i anaxoMMM opraHOB ujen yweib o6bacHMTB npoMcxo>KfleHMe Han6onee nacrbix CMMHTOMOB BOCna/iMTe/ibHbix 3a6ojieBaHMfi ITIOTKM, MexaHnawbi
TOHSWlJlOreHHblX OOlOJKHeHUM.
1. Bwfle^MTb na ocHoae ronorpacpMM FJIOTKM BOSMO>KHbie nyxM pacnpocTpaneHMfl MHCpeKUMM K ApyruM opranaM n cucreMaM.
2. HsyHMXb
CpyHKL(MOHaJlbHOe
3HaH6HHe
1. Condamoe \A. B. JleKLiMM no OTopMHonapuHro/iormi. — M.:
1990.
2. LUeepbiauH B. B. PyKOBOflCTBO no flercKoii OTOpuHonapMHronornn. — M.:
MeflMijMHa, 1985.
3. J]MumpueHKo M. Arnac KjiMHUMecKofi aHaTOMMM'(oTOpMHonapMHronorn$i). —
MocKBa,1998.
MMHflailMH
Konbua nnporoBa-Banbfleepa. BbiflenMTb Ha ocnose anaTOMO-CpM3MOJlOrV1HeCKMX OCO6eHHOCT6il MMHfla/IMH OCHOB-
Hbie 3B6HbH narorenesa xpoHMHecKoro TOHSunnma.
3. 3a«pennTb naabiKH MHCTpyMeHTa^bHoro nccnefloBaHMfl I710TKM.
JJonofiHumenbHo drift neduampuyecKoao cpaKy/ibmema:
4. MsysMTb anaTOMMHecKMe oco6eHHOCTM MHHflanun
KOJibqa FluporoBa-Ba/ibfleepa y flereii.
5. MsynnTb anaTOMUHecKne oco6eHHOCTM oKonornoTOMHoro npocrpaHCTsa y flerefi paHHero n MJiaflwero
Bospacra, MX KnunnHecKoe
I. KJIMHMHECKAfl AHATOMM?! TJIOTKH
(pharyngs) — nontiH MtimeHHO-(j)H6pO3HtiH opran, KOxoptiH
BpeMCHHO HBnaerca nacrbK) nHmesapHTejibHoro xpaicra H BOsayxonpOBO/wmnx
rryreii. HaiHHaerca rnoxKa or ocHOBaHHa Hepena, na CBOCM npoxaxceHHH HMCCT
coo6meHna c nonocxaMH HOCE, pxa, ropxaHH H npofloiDKaexca B nHmesofl,
acb ox Hero HH>KHHM KOHCxpHKXopOM TJIOXKH (CM. pnc. 4 FIpunoHceHHa).
IloJiocxb rjioxKH cyacHBaexca KHH3y H HMCCX HCCKOJibKO cmnomeHHyio B
He-sajmeM HanpaB^eHHH <})opMy.
BepxHaa cxeHKa FJIOXKH — CBOfl (fornux pharyngs) — cooxBexcxByex napyaCHOH OOBCpXHOCXH OCHOBaHHH Hepena, OrpaHHHCHHOH JlHHHeH, npOBCfleHHOH
cpaKynbmema:
6. BbiflennTb sBenbn MecTHoro MMMyHHTera poroBoii
nonocTM na ocHose MOpctio-cpMsnonornHecKoro eAUHCTea CJ1H3MCTOM poiomoTKn n nonociM pra.
ox raoxoHHoro Syropxa csa^H, nepes COHHMH KaHan H Hapy»Hoe COHHOC oxBepCXH6, BHCpCfl flO OCHOBaHHS MeflHajIbHOH njiaCTHHKH KpblJlOBHflHOrO OTpOCTKa
KJIHHOBH^HOH KOCXH.
CT6HOK mOTKM, OCO66HHOCTM CnH3MCTOM fTlOTKM H3 p33-
SaflHHfl cxeHKa TJIOXKH npmie»HX K noBepxHocxH IWXH BepxHHX iiieHHbix no3BOHKOB, ox^ejiaacb ox HHX npeflnosBOHOHHOH 4>acqHeH (lamina prevertebralis
IUCHHOH (fiacuHH) H saraoxoHHHM (spatium retropharyngeum) KnexnaxoHHUM npocxpancxBOM UICH.
EoKOBbie CXCHKH rnoxKH conpHKacaroxca c KpynHbiMH cocy/jaMH H nepB-
Hbix ypOBHflx, coo6meHHH nonocTM FJIOTKH c
flpyrux opraHOB;
CXpaHCXBC.
ripu nodaomoeKe K aanamuio noemopumb
c npeduiecmeyiomux Kypcoe:
— us Kypca HOpMa^bHoii anaTOMMM — crpoeHne
HblMH CXBOJiaMH IIICH, paCnO^WKCHMblMH B GOKOBOM OKOJIOFJIOXOHHOM
npO-
TeMa III. rJlOTKA
48
HepeflHaa cxeHKa oxcyxcxByex Ha 6ojibiuoM npoxaxcenHH, o6pasya
coo6meHHH c nonocTbK) Hoca, nojiocxbio pxa, nonocxbio ropxaHH. COOXBCXCX-
pacnojiaraioxcfl aH4)<J)y3Hbie CKomieHHa JiHM(})OHZiHbix sjieMenxoB H
jiHM(J)OHflHbie 4>ojuiHKyjibi. K 6oKOBbiM cxeHKaM raoxKH (J)OJinHKyjibi rpynnHpy-
BCHHO 3XHM COoGmCHHflM e/IHHyK) JlOHOCXb FJIOXKH yCJIOBHO fleJMX Ha HOCOFJIOX-
lOXCa B JIHM(})OH4Hbie BaJIHKH.
Ky, poxomoxKy H ropxaHomoxKy.
HocomoxKa — sepxHHH 3xa»c FJIOXKH (epipharyngs) — orpaHHHCHa CHHsy
ox poxorjioxKH MbicjieHHbiM npoflOJDKeHHeM TBepfloro He6a. Saflnaa cxeHKa HOcorjioxKH cooxsexcxByex xenaM l-2meHHbix IIOSBOHKOB. Ha sa/iHe-BepxHCH
CnepeflH poxomoxKa coo6maexca c nojiocxbK) pxa nepea 36B. SCB orpaHHHCH
csepxy CBo6oflHbiM KpaeM Mancoro ne6a, jiaxepanbHO — nepeflHHMH H saflHHMH ne6-
CX6HKC HOCOFJIOXKH pacnOJIOMCCHO CKOnJICHHe JIHM<}>OHflHOH XK3HH - FJIOXOH-
naa MHHflajiHHa (tonsilla pharyngea, s. Adenoidea, MHHflanHHa JlrouiKe). MHH.najiHHa HMeex CKjiaflnaxoe cxpoeHHe, COCXOHX H3 4-6 carHxxantHO pacnono>KeHHbix flOJiek. JIaKyHH FJIOXOHHOH MHHflanHHbi Herny6oKHe, HaHGonee Bbipa5Kena uenxpajibHaa JiaKyna, Koxopaa se^ex B He6oJibiiioe yniyGjieHHe — rnoxoHHbiH KapMan. B aexcKOM Bospacxe, nanHHaa npHMepno c 2-3 Jiex, HaGnioaaexca paapacxaHHe JIHM(J)OH^HOH XKaHH FJIOXOHHOH MHH^anHHbi (CM. pnc. 5
SHaneHHe rHnepxpo<})HH TJIOXOHHOH MHH^ajiHHbi CBasano c
aKXHBHbIM pa3BHXHCM H COSpCBaHHCM HMMyHHOH CHCXCMH, CXaHOBJieHHCM
06-
me8 peaKXHBHGCXH opraHHSMa. Hnorfla yBenHHCHHe pasMepa MHHaajiHHw nacxojibKO 3HaHHxenbHO, HXO MHHflanHHa flocxHraex oxBepcxHH xoan, ycxbeB cnyXOBHX xpy6, HXO aaxpyanaex Hocoaoe auxaHHe, BbisbiBaexflHC(j)yHKi;HiocjiyxoBMX xpy6. B SXHX cjiynaax rHnepxpo<J)Ha MHHflajiHHH pacnenHBaexca KaK naxococxoaHHe H OOOHOKHX JICHCHHIO. MaKCHManbHoro pasMepa MHH^aaocxnraex K Bospacxy pe6eHKa 5-7 JICT, B aanbHeHiueM nponcxo^HX ee HHa, Koxopaa aasepmaexca K nepnoay nonoBoro cospeBaniia.
cxeHKa HOCOFJIOXKH npaKXHHecKH oxcyxcxByex H nocoraoxKa noxoan UIHPOKO coo6maexca c nonocxbro noca.
Ha SOKOBHX cxeHKax HOCOFJIOXKH na ypOBHe saflHHX KOHUOB HHJKHHX HOCOBWX paKOBHH Haxo^axca raoxoHHbie oxBepcxna cnyxoBbix xpy6. XpaiueBbie BaHMKH cjiyxoBbix xpyG necKOJibKO BbiAaroxca B npocBex HOCOFJIOXKH. Csa^H ox
^ i xpameBbix BajiHKOB pacnojiaraioxca HeGojibiune yrjiyGneHHa, me naxoaaxca
\a JIHM4)OHflHOH XKaHH - Xpy6HbIC MHH^aJIHHbl. Tpy6HbIC
HOKpblXbl MHOrOpaflHbIM UHJlHHflpHHCCKHM MCpUaXCJIbHblM SHMXCJIHCM.
CHHsy HocomoxKa HenocpeflcxaeHHo nepexo^Hx B poxoraoxKy. Ox
He6a naHHHaexca H CBeuiHBaexca B nonocxb TJIOXKH MarKoe He6o
MtinieHHaa ruiacxHHa, noKpbixaa CJIHSHCXOH. HpH coKpameHHH sepxHero KOHCXpHKxopa FJIOXKH BO speMa rjioxaHHa Mareoe He6o nproiexcHx K saaneH CXCHKC
FJIOXKH H pasAejiaex OOJIOCXH HOCO- H poxoraoxKH MetKffy coGon. no^BHHCHOcxb
MarKoro ne6a snanHxejibHO BJiHaex Ha SBynnocxb ronoca. IIpH napesax Marxoro
He6a rojioc npnoGpexaex HOCOBOH OXXBHOK npn npoH3HomeHHH JiioSbix 3ByKOB — oxKpbixaa rnycaBocxb.
3a^Haa H GOKOBHC CXCHKH poxomoxKH aBJiaroxca HenocpeacxBCHHbiM npo*
49
I. KnuHMHecKaH anaxoMnn rnoxKM
flOJDKCHHeM
CXCHOK HOCOFJIOXKH. Ha SaflHCH CXCHKC pOXOFJIOXKH HOfl CJIH3HCXOH
HblMHffyyKKSMK,CHHSy - KOpHCM aSbDCa. Me»3y nepe^HHMH H 3a#HHMH He6HbIMH
pacnojio»em,i MKH^anHKOBbie HHIIIH (6yxxbi), B Koxopbix HaxoflHxca CKonjfflM(J)afleHOHHHOH XKaHH — neSHbie MHHflajfflHbi (tonsillae palatinae). Us BCCX
FJIOXKH CXpOCHHe HC6HbK MHHflaJfflH HaHGojICC CJ10»CHOe. rHCXOJIOrHHeCKH
B cocxaBe He6Hbix MHKwanHH Bbmejiaiox nexbipe xjma TKaHH: Hcnnmyio jmMcJiaxHHe- \\f
CKyio — (JjojjJMKyjibi, jmM4)OHaHyio — AH4>(J)y3Hoe cKonncHHe jmM(JK)HnHbix 3JieivieH- XOB, pexHKyjiapHyio (afleHOHOTyio) — pbixjiyio coe.HHHHxejn.Hyio XKaHb, 4>H6po3Hyio
b, oGpasyiouTyio Kancyny (nceBflOKancyjiy) H cxpoMy MHHflaimHbi. IlpH UHTOJIOHCCJie^OBaHHe cocKoGa c He6"HbK MHH/iajiHH B MaxepHane MOXCHO o6napy»arrb KJiexKH BCCX CJIOCB srarrejma, <|)H6po6jiacxbi, MOHOUHXbi, MaKpo^ani, pexracyJiapHbie KJieiKH, JIHM(jK)lIHXbI GoJIblUHC, CpCflHHC H MaJIbie, IIJiaSMOlplXbl, HeHXpo4)HJIbI,
3O3HHO(J)HJIbI, MHeJIOUHXbl p33HOH CXeHCHH 3peHOCXH, SpfflpOUHXbl.
BejiHHHHa HeGHbix MHHflajiHH snaHHxejibHO BapbHpyexca. B cxpoenHH ne6HblX MHHflaJIHH BbWeiWIOX AB3 nOJIIOCa - BepXHHH H HHMCHHH HflBCnOBCpXHO-
CXH — Hapy*Hyio (sesHyio) H BHyxpeHHioio. HH^CHHC nonioca MHHflanHH CBHcaiox nafl KopneM asbiKa. CxpoeHHe MHHflajiHHbi SHannxejibHO oxjinnaexca c napyHCHoii H BHyrpeHHeH noBepxHOCxefi (pnc. 11). BHyxpeHHaa nosepxHOCxb noKpbixa IUIOXHOH, XOJICXOH — ao 1,5 MM, rua^KOH coeflHHHxejibHOH xKanbio (HCCBAOKancyna), Koxopaa co cxopoHbi seaa oxcyxcxByex.
OGpameHHaa B npocsex sesa noBepxnocxb noKpbixa MHorocnoHHWM ruioCKHM snHxejiHCM, Hcnempena MHOHcecxBCHHbiMH mejiaMH (KpnnxaMH, jiaKynaMH), Koxopbie flpeBOBHflHo pasBexBJiaioxca B xojime MHHflajiHHbi. Bojibuiaa nryH H3BHJIHCXOCXb JiaKyH 3HaHHXCJIbHO
nnomaflb Hapy^cHOH noBepxHOCXH npH HeSojIbUIOM oGtCMC MHH^aJIHHbl,
HXO oGecneHHBaex MaKCHManbHyio <J>yHKUHOHajibHyio aKXHBHOCxb oprana. BMCCXC c
XCM, xaKoe cxpoenne cos^aex ycjiosna
saaepxcKH oxflCJiaeMoro MHHflajiHHbi B
nax, oGpaaoBaHHa pexenuHOHKbix KHCX, HXO
H 4>opMHpyex onar xpOHHnecKOH HH^CKUHH.
Kancyjia, MHHflajiHHbi HC cpamena c 60KOBOH CXCHKOH FJIOXKH HOJIHOCXbK). Me^QXy
BHyXpeHHCH
6OKOBOH
nOBCpXHOCXblO
CXCHKOH
FJIOXKH
MHHflaJIHHbJ
HaXO^HXCfl
H
HC-
PuC. 11. He6H351 MHHflajIHHa:
GoJIbUIOH CJIOH pblXJIOH napaXOH3HJUIflpHOH
1 — Tpa6eKyjibi, 2 — JiaKynti,
3 — nceBflOKancyjia
KJiexnaXKH, HXO npH HeoGxO^HMOCXH flCJiaeX
TeMa III. mOTKA
50
I. KnuHMMecKan aHaiOMna rnoxKH
51
nonHoe yaaneHHe ne6HOH MHaaajiHHbi BMCCXC c Kancyjiofi, HO H
npe^nocbiJiKH jvw 4>opMHpoBaHHfl napaxoHSHJiimpHoro a6cuecca npn
JIHH 6es HapyiueHHa <J>yHKHHH oprana — (JmsHOJiorHiecicaa rnnepxpotJiHa.
onpeaejieHHa cxeneHH FHnepxpo<J>HH HeSnbix MHHaaJiHH ycjioBHO aejiax HOJIOBH-
FHOHHOM BOCnaUCKHH MHHUaJIHHbl. BMeCXe C XCM, CBH3b HcGHblX MHHflaJIHH C 60-
Hy 3CB3 H3 XpH paBHHC H3CXH. ECJIH He6H3a MHHa3JIHH3 npHKpblBaCX 33aHK>K>
KOBOH CXCHKOH FJIOXKH flOCX3XOHHO HHXHMH3. 3XHM oStaCHaCXCH p63Kaa 6ojlb B
HeGnyio ayacKy, HO He Bbixoanx sa Hapyacnyio xpexb sesa — HMeexca rHnepxpo4>Ha MHHaaJiHH I cxeneHH, CCJIH MHHaajiHHa naxoanxca B npeaenax cpeaneH xpeXH nojiOBHHbi sesa — HMeexca rHnepxpo(J>Hfl MHHaajiHHbi II cxeneHH. Koraa
MHHaanHHbi Bbiaaioxca B npocBex seBa 6ojiee, HCM na 2/3, 33nonHaa npaKXHnecKH
Becb ero npocsex, B neKoxopux CJiynaax conpHKacaioxca BCPXHHMH nojuocaMH — HMeexca rHnepxpo<J>HS MHHaaJiHH III cxeneHH.
ropne BO Bpeina rjioxamia npn BOcnajieHHH MHHflanHH.
rpammefi poxo- H ropxanorjioxKH ycjioBHO CHHxarox ypoBCHb CBoGoflHoro Kpaa
jienecxKa HaaropxaHHHKa. Kinoy ropxaHoraoxKa cy>KHBaexca B nepeflHe-saflHCM H3npaBJieHHH H B BH^C nonepeHHOH mejra nepexoflHx B nnmeBoa. HHKHSH rpaHHua
ropxaHornoxKH HaxoflHXca Ha ypOBHe muKHero Kpaa nepcxneBHaHoro xpama cnepeAH, na ypOBHe xeji meftHbix HOSBOHKOB Cyi-Cvii — csa^H. Ha nepeflHefi cxemce ropxaHoraoxKH caepxy pacnonaraexca Kopem. aswica, CHHsy — Bxofl B ropxanb. JlaxepanbHO ox Bxoaa B ropxanb, MOK^y BbicxynaiomHMH xpamaMH ropxaHH H OOKOBHMH
cxemcaMH ropxaHoraoxKH Haxoaaxca rpymeBHflHbie cmrycbi (KapManbi). FpyuieBHaHbie CHHycbi nojiHOCxbio oxKpHBaioxca npH (JtonauHH (HCM noju>3yexca oxopHHOJiapHHrojior npH mno^apHHrocKonHH) H BO speMa raoxaHHa, B CBSSH c HCM B rpyiiieBHflHbix CHHycax nepe^Ko 3acxpeBaiox HHOpo^Hbie xejia.
Ha Kopne a3biKa sa xcejioGoBHflHHMH cocoHKaMH pacnojiaraexca cKonjieHHe
JIHM(J)OHflHOH XK3HH
a3bI4H3a MHHfl3JIHHa (tOnsill3 HngU3lis). llo Cp3BHCHHK» C
He6HbIMH MHHflajIHHaMH JIaKyHbl aSblHHOH MHHflajIHHH MCJIbHC, p33BeXBJieHHOCXb
jiaxyn snaHHxejibHO MCHbiue, a ycxbs Jianyn mnpe. B aswHHOH MHHflaJiHHe 6ojiee
pasBHxa cexb KpOBenocHbix cocyflOB, 6ojibiue coaep»CHXca CJIHSHCXHX xcejies.
HeGnbie MHHflajiHHbi, HOCorjioxoiHaa MHHflajiHHa, xpy6Hbie MHHflajumbi H
asbiHHaa MHHa3JiHHa 6bmn onHcanw snaMeHHTHM pyccKHM xnpyproM, ynenbiM
H. H. HHporoBbiM K3K JiHM(J)O3nHxejiHajibHoe raoxoHHoe KOJibuo. B HasaaKHH oco60 nOAHepKHBajiaCb 6HH30CXb JlHM(})OHflHbIX 3JieMCHXOB K 3HHXejIHK> K3K OflHO H3
ycnoBHH peajiH3at(HH samnxHofi 4>yHKLiHH. Banb^eep H B nocjienyiomeM ero yneHHKH OnHCajIH OXXOaaiUHC OX MHHflajlHH JIHMfJjaXHHCCKHe COCyflH B nOJIOCXb HOCa,
ropxaHH, poxoeyio no/iocxb. HocKOJibicy H. H. HHporoB H Banb^eep nojio^cunn HaHajio Hccjie^oBaHHio MOp4>OJiorHHecKoro H <J>yHKUHOH3JibHoro cocxoaHHa MHHflaJ1HH, KOJIbUO H33BaHO HM6H6M nnpOrOBa-Bajlbfleepa. IIO^HepKHBaa MOp4)OJIOrHHCCKOC CXpOCHHe MHH^ailHH H B33HMOCBa3b MHHflaJlHH MCXyiy CO6OH, OXOpHHOJiapHH-
rojiorH H Mop<J)OJiorH oGieflHHarox MHHflanHHbi B jiHM<})o-afleHOHflHoe TJIOXOHHOC
KOJibqo. YiHTHBaa aHaxoMO-iJiyHKiiHOHajibHoe e^HHcxBo, K KOJibixy IlHporoBaBanbfleepa xaioice oxHecenbi 6oKOBbie BanHKH rnoxKH, JiHM^axHMecKaa xxaHb BBCXHSyjiapnoro oxae^a ropxaHH, JiHM^axHiecKHe 4)OjmHKynbi sa^HeH CXCHKH FJIOXKH.
FnoTOHHaa H He6Hbie MHH^anHHbi npexepnesarox SHannxejibHwe Bospacxnue
H3MCHeHHa. HaH6onee aKXHBHO (JiyHKUHOHHpyiox MHHflajiHHbi ao nonoBoro cospesaHHa. B aajibHCHUieM npoHcxoanx MeaneHHaa HHBoniouHa 4)yHKyHOHajIbH°M
XK3HH MHH43JJHH HpH COXpaHCHHH COeflHHHXCJIbHO-XKaHHOH CXpOMbl. Y HOBOpO-
HflaJiHHbi «Ha<J)apuiHpoBaHbi» pasBHBaiomHMHca 4)OJiJiHKyji3MH.
aKXHBHO <J)yHKUHOHHpyiox, HX Macca nocxeneHHO yBenHHHBaexca. V
HepeflKO Bcxpenaexca yBejiHHCHHe pasMepa He6Hbix H FJIOXOHHOH
V demeu. do lOnem eunepmpotpw mdubix Mundajiun ll-III
cmeneuu npu omcymcmeuu npwnaKoe xponutecKoeo eocnajienwi znornKU, ne conpoeoMcdamu^ancR yicajiodaMU, He aeMemcsi namonozuHecKUM cocmofmueM. Tepmun «j>u3uojiozmecKOfi» zunepmpo(pufi nodvepweaem Koppemifuio MBOKdy pasMepOM u (pymafuoHOJibHou aKmuenocmbio MundcuiuHbi — cocmoHHueM opzana, npu KomopOM opzamaM pe6enm adanmupoean K nocmynaioufeMy nomoxy aHmuzeuoe.
OKOJiorjioroHHoe npocrpaHCTBO. Ha BCCM npoxaaceHHH 6oKOBbie H
cxeHKH FJIOXKH rpaHHnax c OKOjioraoxonHbiM npocxpaHCXBOM (spatium parapharyngeum), B KoxopoM Bbwenaiox saraoxoHHoe npocxpancxBO (sp. retropharyngeum) H
napnoe 6oKOBoe rnoxoHHoe npocxpaHcxBO (sp. lateropharyngeum). Pbixjiaa coeflHHHxxanb OKOJioraoxoHHoro npocxpaHCXBa ooecneqHBaer no/pHWHocxb TJIOXKH i
FJIOX3HHH.
3arjiOTOHHoe npocrpancTBO orpaHHHeHo csa^H npeanosBOHOHHOH 4>acqHCH, cnepeflH — FJIOXOIHOH (JjacuHefi, noKpHBaiomefi saflHioro cxenKy FJIOXKH, c
6oKOB — (JiacuHeH H miexHaxKOH, OKpyjKaromefi Gojibuine cocyflHCXo-nepBHbie
UICH. Ha^HHaerca sarjioroiHoe npocxpaHCXBo ox ocHoaaHHa qepens,
B pexpoasoiJmrajibHoe npocxpsncxBO H nepexoanx B saanee cpeflocxeHHe. Y aexefi paHHero H MJiaauiero Bospacxa — flo 5-n Jiex — iw^poBHe ->
HOCOFJIOXKH B saraoxoHHOM npocxpancTBe pacnonaraioxca jiHM^axniecKHe ysJIM, npHHHMarouiHe jiHM<}>y HS nonocxn noca, QKOJIOHOCOBHX nssyx H cpeanero
yxa. FIpH HX HarHoeHHH 4>opMHpyexca saraoxoHHwid aScyecc. PacnojiroiceHHe
JiHM<J)oy3JiOB sarjioxoHHoro npocxpancxBa o6ycjioBjiHBaex npeHMymecxseHHO
Bepx-HK)K) JiOKajiHsauHio 36cu;ecca, HHor^a aGcueflnpyioiuHH jiHM(J)oy3eji onycKaexca RO ypoBHa poxomoxKH. V B3pocjibix nepes samoxoiHoe npocxpancxBo B
saflHee cpeaocxcHHe Moacex onycKaxbca rHOHHHH naxex cnoHanjioreHHoro reHesa.
EoKOBoe rjioroHHoe npocrpancTBO cnepean orpaHHHHBaexca BexBbio
HH»HCH HCJHOCXH, c33flH — npeflno3BOHOHHOH $3caHeH, jiaxepanb
^HeH oKOJioyuiHOH acejiesbi, MeanajibHO — KpbiJiOBHflHOH MbimueH.
ox ocHosaHHa nepena, SOKOBOC raoxoHHoe npocxpancxBO Ha ypOBHe
52
TeMa III. TJ1OTKA
KOCTH nepexoflHX B cpeflHHHyw mejib men, Koxopaa orpaHHHena
HCH, noBepxHocxHOH H rjiy6oKOH uieHHbiMH (JiaciHiaMH. CpeflKHHaa mejib uien
npofloJDKaexca B sa^nee cpe^ocxeHHe. B GOKOBOM FJIOXOHHOM npocxpaHcxse
npoxoflHx KpynHbiH cocyflHCXo-HepsHbiH nynoK men, KoxopuH COCXOHX HS
BHyXpCHHCH COHHOH apxepHH, BHyXpCHHeH apCMHOH BCHbl H HCpBOB
CHMHa-
xH^ecKoro cxaojia, 6jiy3Kflaiomero, no.m.HSbiHHoro, sBMKomoxoHHoro H flo6aBOHHOFO HCpBOB.
BaotcHocmb oKOJiozjiomouHOZo npocmpancmea e KJIUHUKC
odycjioejiena eosMOOKHOcmbio paseumusi ZHOUHOZO ueduacmeHuma npu eocncuiumejibHbvc 3a6ojieeamisix zjiomiai.
KpOBOCHa6»ceHHe FJIOXKH ocymecxajiaexca HS SacceiiHa HapyncHOH COHHOH
apxepHH:
— Bocxoaaiuefi He6noH apxepHeii HS Bocxoflsmen FJIOXOHHOH apxepHH;
— HHcxoA»meH HeSnoH apxepneii HS BepxHenejuocxHoii apxepHH;
— sexEHMH nHu,eBOH apxepHH;
— BepxHeS IUHXOBHJIHOH apxepneii (o6;iacxb ropxaHorjioxKH).
OcoSeHHocxb KpoBocHa6»ceHHa HeGHtix MHH^ajiHH saKJiioHaexca B XOM, HXO,
"noMHMO BexBefi ox yKasannbix apxepnii, MHHflajiHHbi HHor^a HMCIOX caMOcxoaxeJibHyro MHHflajiHKOByio apxepnio, Koxopaa MO^CX ncxoAHXb KaK HS jno6oH aexBH, XaK H HenOCpCACXBCHHO H3 HapJQKHOH COHHOH apxepHH.
BenosHbiii OXXOK HanpaBJieH B nepeanee H sa^nee OKOJIOFJIOXOHHWC cruiexea. ITepeflHee OKOHOFJIOXOHHOC cruiexeHHe (plexus pharyngeus anterior) JioKajinHa MarKOM neSe, uinpOKO anacxoMOSHpyex c saflHHM OKOJIOFJIOXOHHHM
craiexcHHeM, KpbinoBHflHbiM BCHOSHWM cnjiexeHHeM, asbiHHoii Benoii H BenaMH napyacHoro noca. 3a#Hee OKOJIOFJIOXOHHOC croiexeHHe (plexus pharyngeus posterior)
pacnojiTOKCHO na Hapyacnoii noaepXHOcxH GOKOBOH H saflHefi CXCHOK FJIOXKH, HIHpoKO anacxoMOSHpyex co BCCMH BCHOSHLIMH cmiexeHHaMH UICH. KpoBb HS BenosHbix crorexeHHH co6npaexca B FJIOXOHKHC BCHH, Bnaflaromne BO BHyxpeHHioio
apeMHyro Beny.
JlHM(J)axHHecKHe cocy^bi FJIOXKH mnpoKO anacxoMOSHpyiox c JiHM<J)axHHeCKHMH cocyaaMH nojiocxeii noca, pxa, ropxann (CM. pnc. 6 DpHJioxceHHa). OHH
jiHM<J)y B 6jiH3^e)KamHe sarjioxonnbie jiHM<})oy3Jibi, B jiHM(})oy3Jibi no
BHyxpeHHeft apeMHoii BCHH. HHM^OOXXOK ox He6nbix MHHflajiHH ocymecxBnaexca B JiHM(J)oy3jibi, pacnojioxceHHbie no nepeflHCMy Kparo KHBaxeJibHOH
Mbimubi B BepxHeK xpexH men (sanejiiocxHbie JiHM(J)oy3Jibi). npHBO^amnx JIHM4>axHHecKHx cocy^oB see MHHaajiHHbi jiHM^aaeHOHflHoro FJIOXOHHOFO KOJibiia
ne HMCIOX.
HHHepBaiiHH FJIOXKH ocymecxBJiaexca HS FJIOXOHHOFO HepBHoro cnnexcHHa,
Koxopoe COCXOHX HS BCXBCH xpoHHHHHoro, asHKornoxoHHOFO, 6jry>KflaK)mero,
flo6aBOHHoro nepBOB H BexBeK HS BepxHero UICHHOFO CHMnaxHiecKoro ysjia.
II. <t>n3nonornfl rnoxKM. Mexoflbi nccneflOBaHMn TJIOTKH
53
ii. a>H3kiojiorvm FJIOTKH. METOABI
rnoTKM
B cHny CBOCFO pacnojioxceHHS na nepeKpecxe ^bixaxejibHbix nyxen H
pHxejibHoro xpaKxa FJioxKa yHacrayex B 4>opMHpoBaHHH OKpacKH rojioca, o6ecneHHBaex BOSflyxonpOBeflCHHe, naccaK nHmesoro KOMKa B nnmeBoa, ynacxByex BO
BKycoBoft peuenqHH, o6ecneHHBaex saujHxy flbixaxejibHHx nyxcH BO BpeMH naccaaca HHIUH. CjiHSHcxaa FJIOXKH H nHM^oaaeHOHAHbie opranbi FJIOXKH ynacxByiox B
HecneuH<J)HHecKOH H cneuH^HnecKOH HMMynnoH samnxe opraHHSMa, B KPOBCXBOpeHHH, asjiaioxca orpoMHtiM peuenxopHbiM HOJICM, oKasbisaiomHM HeHpo-pe(J)JieKXOpHOe BOSflCHCXBHC H3 (JtyHKUHIO OXflaJICHHblX OpraHOB! CepflUa, nOHCK, aHHHHKOB,
Mbiunjbi FJIOXKH oGecneHHBarox HenponsBOJibHyio nacxb aicxa raoxaHHa.
(OpoHSBOJibHaa nacxb axxa FJioxaHna ocymecxBJiaexca B poxosoH HOJIOCXH). CoKpameHHe BepxHero KOHCxpHKXopa FJIOXKH H nofltCM MarKoro He6a oxrpanHHHsaiox nonocxb HOCOFJIOXKH, KaK xojibKo nnuieBOH KOMOK flocxnraex He6Hbix ay5KCK. DocjieflOBaxejibHoe BOJiHooGpasnoe coKpamenne cpeflnero, HHHcnero KOHCXpHKXOpOB, UIHJIOFJIOXOHHOH MblUIIfbl npOXaJIKHBaiOX HHmeBOH KOMOK B nHIIie-
BO.H. CoKpameHHe Mbiiun, KpenamHXca K nofltasbiHHOH KOCXH noflHHMaex ropxaHb xaK, ixo jienecxoK naflropxaHHHKa saKpbisaex BXO# B nojiocxb ropxann ox
nnmeBoro KOMKa. HOMHMO nnmeBoro KOMKB B nnmeBoa orreKaex HOCOBOH CCKpex H cniOHa, Koxopbie nocxoaHHO ysjiaacnaiox noBepxnocxb MHorocnoHHoro
njiocKoro annxejiHa, Bbicxnuaiomero nonocxn poxo- H ropxanorjioxKH. B csasn c
3XHM naXOHOFHHeCKHe COCXOSHHa HOCOBOH HOJIOCXH H nOJIOCXH pxa
HeSaMCflJIH-
xejibHO BbisbiBaiox peaicnHio co cxoponu CJIHSHCXOH o6ojioiKH H opranoB FJIOXKH
H (JiopMHpyrox xpoHHHecKHH BocnajiHxejibHHH npouecc. '
CxpoeHHe nojiocxH FJIOXKH — o6tcM ropxano-, poxo- H HOCOFJIOXKH, xonyc
FJIOXKH H MarKoro He6a, pasMep H nojiOHcemie FJIOXOHHOH H He6nbix MHH, He6HOH sanaBecKH — BJinaex na OKpacKy (xeM6p) rojioca, sa cnex nero
peajiHsyexca pesonaxopnaa 4>yHKuna.
CjiHSHCxaa FJIOXKH H jiHM^oaflCHOHflHoe FJIOXO^HOC KOJibuo nrpaiox HCKJHOHHXCJIbHO BaaCHyiO pOJIb B (J)OpMHpOBaHHH MCX3HH3MOB CneUH(})HHeCKOH H
HecneuHcJmHecKOH HMMyHHofi samnxbi opraHHSMa. OyHKUHOHajibnas aKXHBHOCXB MHHaajiHH jiHM(})oafleHOHflHoro FJIOXOHHOFO KOJibqa H3H6ojiee BticoKa
ao nojioBoro cospeBanHa. C HOSHUHH coBpeMCHHtix snaHHH o MOp4>o4)yHKopraHHsaqHH MHHflajiHH FJIOXOHHOFO Ko^bua, OHH asjiaioxca peHMMynoperyjiaxopHbiMH uenxpaMH no OXHOUICHHIO K KonxpoCJIHSHCXHM o6ojiOHKaM. XapaKxepHoe AJia aexcKoro Bospacxa coHOBbiuieHHOH anxHreHHOH narpysKH c HMMyHOfle<}>HLHixHbiM cocxoaHHCM npHBOflHX K nOBHUieHHK) (JiyHKUHOHaJIbHOH aKXHBHOCXH
HOH XKaHH.
54
Ten/ia III. TJIOTKA
xKann raoTOHHoro KOJibua B Hecneqn(J)HHecKOM
HMMyHHxexe peannsyexca nocpeflcxBOM cjieayioinHX MexaHHSMOB:
— Gapbepubie CBOMCXBa anjrrejmajibHOH BHCTHHKH, oco6eHHOCXH crpoeHHa 6aOH MCM6paHbi 3mrrejina, B HOpMe He npommaeMbie ana HyacepoflHbix arenxoB;
MexaHHHecKaa 3BaKyan,Ha B npocsex JiaKyn (H aanee B nojiocxb FJIOXKH,
nyacepoaHbix arenxoB BMCCXC c npo^yKxaMH acH3HCfleaxenbHOCXH MHHflaJIHHbi;
— npoflyuHpoBaHHe necneuH^HHecKoro (JmKxopa npoxMBOSHpycnoro HMMyHHxexa — HHxepcjjepoHa;
— 4)arouHX03 MHKpoopraHHSMOB H opraHHHCCKHX H neopraHHHecKHX coeflHHeHHH, HX paspyuieHHC jiHSOcoMajibHHMH <f»epMeHX3MH HCHxpocJjHJioB, M3Kpo<}>aroB;
— GHOiymnocxb HeiixpofJjHJiOB B OXHOUICHHH nio6oro (Jmicxopa, cnocoGaoro
Bbi3B3Xb aicxHBau,HK> HeHxpocfiHJia, CBasaHHaa c MOIUHHM BbiSpocoM aKXHBHbix
Mexa6ojiHxoB KHcnopofla;
— BerexauHa HOpMajibHOH MHKpo(j)Jiopbi, KOHKypenxHO CflepHCHBaiomeH pocx
naxoreHHbix iiixaMMOB.
CneuH(})HHecKHH HMMyHHxex peajiHsyexca sa ciex BsaHMOfleficxBiw aHXHreHnpeflCxaBJiaiomHx H BcnoMoraxenbHbix KJICXOK jinM(J)oiiHxapHoro pa^a, 4>opMHpyromero HMMynorjioGynHHOByio aaiuHxy CJIHSHCXOH o6ojioHKn. PesyjibxaxoM
BbipaGoxKH cneuH(J)HHecKHx aHXHxen aBJiaroxca:
— orpaHHHCHHe KonoHHsauHH MHKpoopraHHSMOB Ha snHxeJiHH sa cnex noBepxHocxHbix HMMyHorno6yjiHHOB KJiacca IgA;
— OHHmeHHe ox npOHHKLUHX Hepcs snHxejiHH naxoreHOB 33 C4CX HX pacno3H3BaHHa, HH3KXHBaUHH H flCCXpyKUHH FyMOpaJlbHblMH (IgM
H IgG)
H KJICXOHHO-
(ceHCJi6HJiH3HpoBaHHbie JIMM^OUHXH) MexaHHSMaMH.
MCCXHOFO HMMynnxexa na cneuH(J)HHecKHH H HecneuH(J)HHecKHH
yCJIOBHO, X3K K3K O&3 3BCH3 H3XOflaXCa BO B33HMOflCHCXBHH H B3aHMOH3MCHaeMbI.
PerynauHa MecxHoro HMMynnxexs onpeaejiaexca B33HMoaeftcxBHeM M3Kpo4>aroB,
Heiixpo4)HJiOB, snnxejiHajibHbix itnexoK, c T- H B-jiHM(j)ou,HxaMH KaK nenocpeACxBCHHO, X3K H C OOMOmbK) IJHXOKHHOB.
MHHflajiHHbi npHHHMaiox ynacxne B KpOBexBopeHHH, nocKOJibKy B HHX npoHCXOflHX o6p330B3HHe JIHM(J>OLIHXOB. HoBOo6pa30B3HHe JIHM(J)OUHXOB
flHx pasHbiMH cnocoGaMH: H3pa^y c MHXOSSMH B (JjOJiriHKyjisx BCTpeqaioxca
xoxHHecKH flenamHeca KnexKH, Bcxpenaexca noiKOBaHHe.
MHHwajiHHbi raoxoHHoro KOJibua coaepxcax CJIOSCHWH nepBHUH annapax, B cocxas Koxoporo BXOJWX SUCMCHXH a(J)<J)epeHXHOH H 3(j)(J)epeHXHOH HHHepBauHH.
HepBHbie sjieMCHXH pacnojioaceHbi BO BCCX XKanax MHHflanHH: B 4)oiuinKyjiax, B
snHxejiHH. B cyGsnHxejiHMbHOM npocxpancxBe pacnonaraioxca nepHjiaKynapHbie
HepBHbie cruiexeHHa, HepBHbie peuenxopw pacnojioacenbi no Bceft napenxHMe. IlojiHMop<J)H3M nepBHbix peqenxopoB o6ocHOBbiBaex nonoHccHHe o HCHpo-pe(})jieKXOpHOM MCXaHHSMC BOSflCHCXBHa MHHflaJIHH rJlOXOHHOFO KOJIbUa Ha <J)yHKUHOHaJIb-
HOC cocxoaHHe pasjiHHHbix CHCXCM opraHHSMa. TaK, H. B. ConaaxoBbiM B 1951 r.
II. <t>M3i/ionornfl rnoxKM. Meroflbi MCcnefloeaHmi rnoxKM
55
6bui onHcaH H noflXBep»meH SKcnepHMCHxanbHO xoH3Hnno-KapAnajibHbiH pe(J)jieKc:
HSMCHCHHe pa6oXbI CCpflCHHOH MblUJUbl B OXBCX H3 paSapaxCCHHC HC6HOH MHHfla-
JIHHH. 3KcnepHMeHxanbHO 6bina noKaaana csasb Meayry fljiHxeJibHoft a(J)4)epeHTHOH
neSHbix MHHflajiHH H PSSBHXHCM flHcxpo(})HHeCKHX HSMCHCHJIH
6ojibHbix XPOHHHCCKHM XOHSHJUIHXOM xoHSHJUio-KapflHajibHbiH peij)JICKC Gojiee Bbipsacen, HCM y sflopOBbix nioaeH. B aajibHCHiiieM 6bin onHcaH H BKCnepHMCHX3JibHO noflXBepaqieH xoH3Hjino-6poHXHanbHbift pe(J)JieKC.
Meroflbi
TJIOTKH
HocorJIOTKH. HccjieaosaHHe HOCOFJIOXKH HaHHHaiox co c6op3
>K3JIO6 H3 H3pyUICHHe 4>H3HOJIOrHHCCKHX ^yHKUHH HOCOFJIOXKH H OCMOXpa BHCUIHerO
cxpoeHHa jiHu,a (afleHoiwHbiH xnn), HXO KOCBCHHO IIOSBOJIHX sanoaospHXb naxojiornqecKoe cocxoaHHe opranoB HOCOFJIOXKH. HccneaoBaHHe HOCOFJIOXKH y flexefi psHHero
BO3paCX3 3H3HHXeJTbHO 33XpyflHCHO. MO)KHO H3H3Xb HCCJieflOB3Xb HOCOrJIOXKy C HCpeflHCH pHHOCKOHHH HOCJie XmaxeJIbHOH 3HCMH33UHH CJIH3HCXOH nOJIOCXH HOC3. OflH3KO B 3XOM CJiyHaC OCMOXpCXb SaflfBOK) CXCHKy FJIOXKH, OIjeHHXb COCXOaHHC JIHM(j)OHflHOH XK3HH HOCOrJIOXKH BO3MO3KHO XOJIbKO HpH IIIHpOKHX o6mCM H HJOKHCM HOCO-
Bbix xo/iax. IlepeflHaa pHHOCKonna flonojmaexca soH^HposaHHeM HOCOFHOXKH.
IIpH H6B03MOHCHOCXH BH3yaJIbHOFO HCC^eflOB3HHH HOCOraOXKH UIHpOKO HC-
( nojibsyexca ee nsjibueBoe Hccne^pBaHHe. y aexefi cxapmero Bospacxa w* ocMOxpa
HOCOFJIOXKH npHMCHarox sa^Hioio pHHOCKonHio. flflx Jiyniiiero o6sop3 MarKoe He6o
nojrrsrHBSiox K xsepflOMy He6y MancHM soimoM qepes HHXCHHH HOCOBOH XOA.
,f
HanGojiee HH<J>opMaxHBHO HOComoxKy MOHCHO ocMoxpexb c noMombio SH^OCKona co CXCKJIOBOJIOKOHHOH OHXHROH (MHKpopHHOCKonHa).
HccjieflOBaHHe poxoraoxKH, K3K npaBHJio, ne Bbisbmaex ssxpyaneHHa. Bnsy3JibHo Hccjie^yexca poxor;ioxK3 c noMombio uinaxejia npn Meso^apHHrocKonHH.
IlpH HCoSxOflHMOCXH H3fl3BJIHB3HHeM H3 HCpeflHIOtO He6HyK> fly^CKy BblBHXHBa-
iox He6Hyro MHH^anHHy H oijeHHBaiox ee cocxoaHHe. ECJIH HMeexca npenaxcxBHe
Henocpe^cxseHHoro BHsyanbHoro Hccjie^oBaHHa (onyxonb, xpH3M aceBaMycKyjiaxypbi H x. fl.) MO>KHO Hcnojib3OBaxb cxeicnoBOJioKOHHyio OHXHKy. ,ZJjia 6ojiee aexsjibHoro HCCJie^oBaHHa KOHKPCXHOH oGjiacxn poxorjioxKH
Hcnojib30B3Xb OCMOTP c noMombio onepsqHOHHoro MHKpocKona.
cjieflOBaHHe ropxaHomoxKH npoBO/iax BHsyanbHo np« nenpaMOH (sepH) rnno^apHHrocKonHH. B panneM H MJiaAiiieM ACXCKOM Bospacxe npoBOnxr npaMyio THnoiJiapHHrocKonHio c noMonjbio jiapHHrocKona (MOMCHO Hcnojib30B3Xb mnsxejib THxoMHpoBa, 33O(j)3rocKon). HccjieaoBaHne npoBO^ax B HOJIOHCCHHH pe6eHKa Jieaca Ha CHHHC.
IIoMHMO BHsyajibHbix HCHOJibsyioxca AonojiHHxeJibHbie MCXOAW nccJieaoBaHHa: peHxreHOJiorHMecKHe (peHxreHorpa(J)Ha, xoMorpa<})Ha, KOMnbioxepHaa XOMOrp3(J)Ha); 5MP-xoMorp3<j)na; 63KxepHOJiorHHCCKoe,
necKoe HCCJICAOBSHHC.
56
Teiwa III. TJIOTKA
Bonpocbl MTOroBoro KOHrpo/in 3H3HMM no rewe I
1. nepeHMcnme MMHAanMHbi, BxoAamne B
ro Konbqa duporoBa-BanbAeepa.
2. KaxMMM cnoco6aMM MOWHO nccneAoeaTb HocomorKy, ecnn npoeeA6Hkie 33AH6M pMHOCKOnUM H6B03MO>KHO?
3. Kaxne o6pa3osaHna coAepxwr sarnoroMHoe npocrpaHCTBO y Aeretf
AO 5-6 ner?
4. B H6M 3aioiK)MaeTCfl KnHHunecKoe SHaneHkie ronorpacpmi OKOJIOrnoTOMHoro npocipaHCTBa?
5. B new aaicnKJMaeTCP cpnanonorMHecKan ponb MUHAanMH nuMdpoaAeHOMAHoro rnoTOMHoro Konbqa?
6. Flo K3KMM npn3H3KaM BbiAenflioT cieneHM runeprpocpnn
7. B new aaioiKDHaeTCfl ocoSeHHOCTb KpoBOCHa6>KeHMyi He6Hbix MMH8. KaK Bbi noHMMaeie repMMH «cpM3nonornHecKaa» runeprpocpua
9. MTO osHanaeT TepMMH «OTKpbiran mycaBOCTb»? B KBKOM cnyMae
BOSHMKaer AaHHoe HapyiueHne peMM?
10. nepeMMcnure BMsya/ibHbie MeioAbi nccneAOBaHun
eivia IV.
yxo: cnyxoeoM AHAJIMSATOP
— 180MHHyr.
HaynnTbcq nccneflosaTb cnyxoeoM
aHannsarop wetOAOM aKyMeipuM, no pesynbTaiaM aKywerPMM n ayAMOMerpmi onpeAennrb run n creneHb TyroyxoCTM.
1 . Pa3o6parb reopvin cnyxa.
2. HayHMTbCH nccneAOBaib cnyx luenoTHoii n pasro3. HayHMTbcn nccneAOBaib
4. Pa3o6parb Tkinu ayAnorpaMM.
5. HayHMTbCfl cocraenflTb cnyxosoM nacnopi.
6. HsynnTb innbi, creneHM ryroyxocTM.
7. OsHaKOMMTbCfl c pa6oToPi Bpana-cypAonora B ayKa6nHeje JlOP-OTAeneHMfl.
JJonofiHume/ibHO dnn neduampuvecKozo
8. OSHaKOMMTbCH C OCO6eHHOCTHMM
cnyxa y AereM.
flononmimenbHO
cpaKyribmema:
9. Pa3o6paib KnuHimecKoe SHaneHne Tonorpacpnn
Hapy>KHoro yxa npM ipaBMax, 3a6oneBaHnax opraHOB
3y6o-MeniocTHOM cMcreMbi.
OcHaiueHMe. OceeTMTeribHbie npn6opbi: MCTOMHMK
cseia, no6Hbiii pedjneiaop, OTOCKOH.
Ha6op MHCTpyveHTOB. Hocoebie sepKana, tunaienn,
yiiiHbie eopOHKM, Ha6op KaMepTOHOB, jpemoTKa BapaHM.
Mecro npoBefleHMfl saHflTMn. VHe6Han KOMHara,
ayAMOwerpHMecKHM Ka6nHer OTOpuHonapuHronornHecKOro
1. Condamoe M. B. JIBKLIMM no OTOpuHonapuHrono. — M.: MeAHUHHa, 1990.
58
Teiua IV. YXO: CJiyXOBOI/1 AHAJ1M3ATOP
2. LUeepbizuH B, B. PyKOBOflCTBO no flercKoii OTOpuHonapuHronormi. — M.:
, 1985.
3. Oe^UHHUKoe K). M. OTOpuHonapMHrojiornn. — M.: MeflMquHa, 1995.
I. KJlMHMHECKAfl AHATOMMfl CJlYXOBOrO
AHAJ1M3ATOPA
HapyacHoe, cpejxHee H BHyxpeimee yxo. Hapymioe yxo COCXOHX
H3 yiiiHOH paKOBHHbi H Hapy^KHoro cnyxoBoro npoxofla. YuiHaa paKOBHHa HMCCX
KOH(j)HrypauHK), ee ocnoBy, 3a HCKjnoneHHeM MOHKH, cocxasjiaex snaxpam, noKpwxbiH Ha/rxpamHHijeH H KOKCH (PHC. 12). B MOHKC coflep»Hxca >KHpoBaa XKanb. CBoGoflHbiH jcpafi yuiHOH paKOBHHbi saKpyraen B BH#C
aBHXKa (helix). HanajibHafl ero nacxb — no»CKa (cms helicis) — pacnoB HcGoJibinoM yrjiy6neHHH (cavitas conhae) naa oxBepcxHCM HapyjKHoro
cnyxoBoro npoxojxa. 3aK3HHHBaexca saBHxoK HesaMexHbiM nepexoflOM B MOHKy
yxa. Ox/iejieHHbiH ox saBHXKa yrayGjieHHCM napajuiejibHo eMy HanHHaexca npoXHBOsaBHXOK (anthelix).
Bmny npoxHBOsaBHxoK o6pa3yex 6yropOK, KoropbiH ysKofi BbipesKofi ox^ejieH
ox KosenKa (tragus). KOSCJIOK asnaexca nacxbio napyxcHoro ciryxoBoro npoxoaa, no
axoMy npH BocnamrrejibHbix 3a6oneBaHHax eapy»cHoro cjiyxoBoro npoxojja ero
nantnauHa 6one3HCHHa. YuiHaa paKOBHHa csasKaMH H MbiumaMH csepxy npHKpenneHa K neuiye BHCOHHOH KOCXH, csa/iH — K cocueBHflHOMy oxpocxKy, cnepeAH — K cKynoBHflHOMy oxpocxKy. YuiHaa paKOBHHa npeacxasnaex coGoft sopoHKy, Koxopaa o6ecnenHBaex onxHManbHoe BOcnpHaxHe 3ByKOB H nrpaex pojib HX
nepBHHHoro ycHJinxena. CymecxBCHHoe SHaneHHe HMCCX xaicace KOCMexHnecKaa
(JiyHKUHa yuiHofi paKOBHHbi. Bornyxocxb ymHOH paKOBHHbi yBejiHHHsaexca B cxopony napy»Horo cjiyxoBoro npoxo^a, Koxopbifi aBnaexca ee HenocpeflcxaeHHbiM npoaon)KeHHeM.
cjiyxoBOH npoxofl Hanpasjiaexca
BHCOHHOH KOCXH H SaKaHHHBaCXCH y
6apa6aHHo8 nepenoHKH. HapyacHbifi ox^eji
cnyxoBoro npoxo^a — nepenoHMaxo-xpa-
3
Puc. 12. ViuHaa paKOBHHa:
1
KO36J10K, 2
pC3Ka, 3
M6>KKO3eJlKOBaiI BblnpOTHBOKO3ejIOK,
4 — MOHKa yxa, 5 — BnaflHHa yuiHOH
paKOBHHbi, 6
npOTHB03aBHTOK,
7 — saBHTOK, 8 — TpeyroJibHaa SMKB,
9
HOJKK3 33BHTKa
mCBOH, BHyXpeHHHH - KOCXHHH.fljIHHaH3-
pyacHoro c^yxoBoro npoxo^a y Bspocjioro, HC
CHHXaa KO3CJIK3, OKOJIO 2,5 CM, flJIHHa KOCX-
HOFO oxflena, o6pa3OBaHHoro 6apa6aHHOH nacxbio (pars tympanica) BHCOHHOH KOCXH (os
temporale) — 1,5 CM. Ko»ca nepenoHnaxoxpameBoro oxaena coaep»cHx MHoroHHCJieHHbie canbHwe H cepHbie Hcenesw, BOJIOCH,
I. KnuHMMecKaa
cnyxosoro aHannsaropa
59
CJIOH no/jKoacHO-acHpOBOH KJiexnaxKH xopouio Bbipaacen. B 3XOM oxaene cnyxoBOFO npoxo^a Moryx BOSHHKaxb (fiypyHKyjibi, oGpasoBbmaxbca axepoMbi, <J>H6poMU, xoHflpoMbi. Koaca KOCXHoro oxflena xoHKaa, jiniiieHa BOJIOC, cajibHbix H cepHMX jKejies, xecHO npHJieacnx K naaKOCXHHue. BocnajieHHe KOHCH B KOCXHOM oxnapy»cHoro cjiyxoBoro npoxo^a npoxeKaex onenb 6oJie3HeHHO, BcneflCXBHe
6ojieBbix peuenxopOB HaflKOCXHHUbi. Ko»a Hapyacnoro cjiyxosoro
npoxoaa o6jiaaaex cnocoGnocxbio K caMoonnmeHHio 6jiaro^apa MnrpauHH 3nnflepMHca H3 rjry6oKHX oxflejios Hapyacy. Xpamesaa ruiacxHHKa nepeflHCH H HH»CHCH CXCHKH npepbisaexcH flsyMa caHxopHHHCBbiMH menaMH (fissurae santorini),
saKpwxbiMH (J)H6po3HOH xKaHbio. 3xo o6ecneHHBaex SHanHxejibHyro noflBH»cHocxb HapyacHoro cjiyxosoro npoxo^a, HXO o6jiernaex OCMOXP H xnpyprHHecKHe
BMcmaxeJibCXBa. CanxopHKHCBbi UICJIH cos/iaiox caasb Hapyxcnoro cjiyxoBoro
npoxofla c OKOJioyiiiHOH CJIIOHHOH acenesoH, HCM oSycnoBJiHBaiox nepexoa HH(JieKUHH H3 HapysKHoro yxa na cjiioHHyio acejiesy H naoGopox.
HanpaBJieHHe H npocsex napyMCHoro cjiyxoBoro npoxo^a B pasHbie sospacxHbie nepHOflbi HMCIOX CBOH oco6eHHocxH. Y HOBOpoacaeHHbix napyacHbiH cnyxoBOH npoxofl HMeex mejieBHflHbiH npocaex, HanpaBJieHHe cnapyacH Bnyrpb, Bsepx
H KnepeflH. Y aexefi MJiaamero sospacxa npocsex cnyxoBoro npoxoaa pacuiHpaexca, HO HanpaBJieHHe coxpaHaexca xaKHM ace. B csasn c SXHM npn oxocKonHH y
aexeft pannero H MJiazniiero sospacxa Heo6xoflHMO oxxanyxb yuiHyio paKOBHHy
Ksa^H H KHHsy, Hxo6w BbinpaMHXb CJiyxoBOH npoxofl.
KjiHHHHecKH BaacHbi xonorpa<})HHecKHe ocoGenHocxH HapyacHoro cjiyxosoro
npoxoaa. IlepeflHaa cxeHKa napyHCHoro cjiyxoBoro npoxoaa rpaHHHHx c cycxaBHOH
cyMKOH cycxaaa HHacHeifnejnocxH. B caasn c 3XHM npn socnajieHHH napy»cHoro
cjryxoBoro npoxo^a 6ojTb B yxe ycHJiHBaexca np« oxKpbisaHHH pxa (pasroaope, »eB3HHH). ripH XpaBMax HHMCHCH HCHIOCXH (npaMUX yflapax B nOfl6opOflOK) HHOFfla
HaGjiKwaexca yiunoe KpOBOxeneHHe, BbisaaHHoe paspbiBOM nepejiHefi CXCHKH cjryxoBoro npoxo^a. Sajjnaa cxenKa cjiyxosoro npoxo^a asjiaexca nepejmeH CXCHKOH
cocqeBHflHoro oxpocxKaTTisMeHeHHa SXOH CXCHKH flaiox ueHHbiH CHMIIXOM flHarnoCXHKH MacxoJWHxa. B CBoen HH^CHCH nacxn B KOCXHOM OXACJIC cjiyxoaoro npoxoaa
cxeHKa naxo^Hxca B HenocpeflcxBeHHOH GJIHSOCTH c jinneBbiM nepBOM.
ci£HKa oxflejiaex cjiyxosoH npoxoa ox cpeztHefi nepenHOH aMKH. Ilpn nepejioMax BepxHeH CTCHKH MOXCCX B03HHKHyxb jiKKsopea, MCHHHrHx. Y aexen panHero Bospacxa npn HesaBepuiCHHOH occn^HKauHH BHCOHHOH KOCXH BocnajieHHe
HapyxcHoro cjxyxoBoro npoxojxa MO*ex conpOBoayiaxbca MCHHHrH3MOM. HnjKHaa
cxeHKajBiinoxHyio npnueraex K OKOJioyiiiHOH CJIIOHHOH jKejiese.
~"
HapyacHoe yxo cnaGacaexca KpoBbio HS cncxeMbi Hapy»HOH COHHOH apxepHH
sa CHCX apxepHH: nosepxHocxHOH BHCOHHOH (a. temporalis superficialis), saxbiJIOHHOH (a. occipitalis), saflHen yuiHOH (a. temporalis posterior), rjiy6oKOH yuiHOH
(a. temporalis profiinda). BeHOSHbifl OXXOK HanpaBJien B Benbi: noBepxHOcxHyro
BHCOHHyro (v. temporalis superficialis), Hejnocxnyio (v. maxillaris), Hapy»Hyio
apeMHyio (v. jugularis externa). JiHMcJpooxxoK H3 napyacHoro cjiyxoBoro npoxo^a
60
Tewa IV. YXO: CnVXOBOM AHAJ1M3ATOP
no jiHM(J)axHHecKHM cocyaaM B jiHMtJmxHHecKHe ysjibi, pacnojioaceHHbie anepeaH ymnoH paKOBHHbi Ha cocueBHaHOM oxpocxKe noa HHrnien CXCHKOH
cnyxoBoro npoxoaa. Hpn BocnajieHHH Hapyacnoro yxa oxMenaexca HX 6one3HeHHocxb. HyBCXBHxejibHaa HHHepBaixHa ocymecxBJiaexca sexBaMH XPOHHHHHOFO,
Sjiyacaaiomero nepBOB, 6ojibuiHM yiunbiM HepBOM (n. auricularis magnum) H3
mcHHoro cnjiexeHHa. BcneacxBHe sarycHoro aKCOH-pecjxneKca npn xyajiexe napyacHoro cjiyxoBoro npoxoaa, npn nonaaaHHH HHOpoanbix xeji B cjiyxosoH npoxoa Moacex BOSHHKaxb Kamejib, KapaHajirHiecKHe asjieHHa.
Cpeanee yxo. Cpeanee yxo npeacxaBJiaex co5oH CHCxeMy BosayxonocHbix nojiocxeH, coo6maiomHxca WY1" c ApyroM H c HOCOFJIOXKOH. B cpeaneM yxe paluiHHarox: 6apa6aHHyio nojiocxb, nojiocxH cocueBHaHoro oxpocxKa, cjiyxoByw xpy6y. PasBHXHC CHCxeMbi cpcaHero yxa saKaHMHsaexcH npHMepno K xpexbCMy roay XCHSHH, K
MOMCHxy saBepuiCHHa OKOCxeneHHa BHCOHHOH KOCXH H cocueBHaHoro oxpocxKa.
BapaSaHHaa nojiocxb — Bosaymnoe npocxpancxBO B nnpaMHae BHCOHHOH
KOCXH, oGteMOM OKOJIO 0,75 CM3, coo6maiomeeca cnepean c nojiocxbio HOCOFJIOXKH, csaan — c nemepofi cocueBHanoro oxpocxKa (pnc. 13). Hojiocxb orpaHHHena mecxbio cxenKaMH, BMeujaex B ce6a cjiyxoBbie KOCXOHKH, ase Mbiiuubi H
6apa6aHHyio cxpyny.
BepxHaa^cxeHKa 6apa6aHHOH DOJIOCXH (tegmen tympany, Kpbima 6apa6aHHofi
nojiocxn) oGpasosana KOCXHOH njiacxHHKOH, oxaejiaromeH 6apa6aHHyio nojiocxb
ox QpeaHeH_iepenHOH aMKH. ToJimHHa ee KOJieGjiexca ox 1 ao 6 MM. Hnoraa B
BepxHefi CXCHKC HMeioxca aHFHCueHUHH, xoraa xBepaaa MosFosaa o6ojiOHKa nenonpHJie>KHx K CJIH3HCXOH 6apa6aHHOH HOJIOCXH. Hepes eepxHioio CXCHKy npoxoaax KposeHocHbie cocyaw H3 xBepaofi
MO3FOBOH O6OJIOHKH K CJIH3HCXOH 6apa6aHHOH
nojiocxH. y HOBOpoayjenHbix H aexen MJiaamero Bospacra B sxoii CXCHKC HMeexca nesaicpbrraa
mejib— fissura petrosquamosa. B SXOH mejin
HHoraa Haxoanxca xaac XBepaofi MOSFOBOH 060JIOHKH, coaepxcamHH KpynHyro Beny. 3xn anaXOMHHCCKHe OCoSeHHOCXH oSlSCHaiOX BO3HHKHOBCHHe MO3FOBbIX CHMnXOMOB npH BOCnajIC-
Puc. 13. Bapa6aHHaa nojiocxb:
1
3TTHK 6apa6aHHOH nOJIOCTH,
2
MOJIOTOH6K, 3
HaKOBajlbHH,
4 — Kman jiHueaoro Hepsa,
5 — cxpeMa, 6 — Kpyrjioe OKHO,
7 — cjiyxoeaH Tpy6a,
8 — BHyipeHHHa apeMHM sena,
9 — 6apa6aHHax nepenoHKa
HHH cpeanero yxa, oGecnenHBarox KOHxaKXHbiH
nyxb HHfJmimpOBaHHa MOSFOBHX oGojioneK npn
cpeancM oxHxe.
_HroKHaa cxeHKa — ano 6apa6aHHOH noJIOCXH (apeMHaa cxeHKa) — Kocxnaa miacxHHKa, ox^ejiaromaa 6apa6aHHyro nojiocxb cmoy
OX nyKOBHUbl BHyXpeHHCH apCMHOH BCHbl. B
cjiynaax B 3x08 CXCHKC HMeroxca 06KOCxHbie aecJieKXbi, xor^a jiyKosnua
apeMHOH BCHLI BWCXOHX B 6apa6aHHyio no-
I. KnuHnsecKafl anaxoMMfi cnyxoeoro
61
nocxb. IlpH 3XOM BO BpeMS onepaiiHH Ha 6apa6aHHofi OOJIOCXH BOSMOJKHO paneHHC BHyxpeHHefi xpeMHOH BCHbi. HMCHHO Hepe3 HH»cHioio cxeHKy B 6apa6aHHyK>
nojiocxb npopacxarox xeMOfleKxoMbi.
IlepeflHaa cxeHKa (coHHaa) rpaHHHHX c BHyxpeHHen COHHOH apxepneH H
npeflcxaBJiaex coSofi xoHKyro Kocxnyio nnacxHHKy. Bepxnaa nojiOBHHa nepeflHCH
CXCHKH, BopOHKOoGpasHO cy»caacb, nepexo^HX B cjiyxoByw xpy6y, pacnojiowenB nojiyKaHane (semicanalis tuba auditiva). Bbime H napajuienbHO en npoxono^yKanaji fljia Mbimuw, HaxarHBaiomeH 6apa6aHHyio nepenoHKy (semicanalis m. tensor tympani).
3aflH«a_cxeHKa (cocqeBHaHaa) HMCCX B CBOCH BepXHefi nacxn uinpoKoe oxBepcxHe (aditus ad antrum), seaymee B nemepy coct^B2iAJHOTOjoxgocxKa.j} HHHCHCH nacxH HMeexca He6oJibiiioe KOCXHOC BO3BbiuieHHe, H3 Koxoporo BbixoflHX cyxo>KHJiHe cxpeMCHHOH Mbiuiuw (m. stapedius). Eme nnace pacnojiaraexca
JIHUCBOFO nepBa. M_gflHajibHaa cxeHKa sxoja B nemepy sanaxa
Hapyacnaa cxenxa (6apa6anHaa) COCXOHX H3 6apa6aHHOH nepenoHKH. KOXOpaa-tmpaHH4HBaex xojibKO cpeflHHH OTACJI 6apa6aHHOH nonocxH ox napyxcHoro
cnyxoBoro npoxoaa, JiaxepanbHOH KOCXHOH CXCHKH aiTHKa, oxrpaHHHHBaiomeH
BepxHHH 3xa»c 6apa6aHHOH HOJIOCXH, HH»HHH sxaxc oxrpaHHHCH jiaxepanbHo
HH^cHefi cxeHKofi Hapy)KHoro cjiyxoBoro npoxo/ia. BapaGanHaa nepenoHKa npe/icxasjiaex coGoft xoHKyro MeMGpany, scxaBJieHHyio B unpKyjiapHbiH »cejio6oK 6apa6aHHoro KOCXHOFO KOJibua (CM. pnc. 7 IlpHJioxfeHHa).
Y BspocJibix 6apa6aHHaa nepenoHKa OBajibHOH 4>opMW, ee SJIHHHHK flocxHraex
0,95-1 CM. EapaGaHHaa nepenoHKa COCXOHX H3 xpex CJIOCB: HapyxcHbifi CJIOH — annC, KoxopwH aBJiaexca npoflOJiaceHHCM KOHCH HapyacHoro cjiyxoBoro npoxoaa;
CJIOH — $H6po3HWH, cocxoamHH H3 u,HpKyjwpHbix H paaHajibHbix coeaHHHTCJIbHOXKaHHblX BOJIOKOH; BHyXpeHHHH CJIOH - nJIOCKHH anHXCJIHH, KOXOpblH HB-
jiaexca nacxbio CJIHSHCXOH 6apa6aHHOH HOJIOCXH. OnGposHbifi CJIOH Geaen ajiacxnneCKHMH BOJioKHaMH, iiosxoMy 6apa6aHHaa nepenoHKa MBJIO ajiacxwiHa H npn pesKHx
SByKax, pesKHX nepenaaax aaBJieHHa ona MOHCCX paspbisaxbca. PenapaxHBHbie npoueccbi B 6apa6aHHofi nepenomce nponcxoaax sa ciex perenepauHH HapyacHoro (KO»a) H BHyipeHHero (cjironcxaa) cnoea. OnSposHbiH CJIOH HC perenepHpyexca.
B 6apa6aHHofi nepenoHKe pasjinnaiox Haxanyxyio H HenaxaHyryio nacxn (pars
tensa et flaccida). HaxaHyxaa nacxb scxaBJiena B KOCXHOB 6apa6aHHoe KOJibuo, HMBex <J>H6p03HbiH CJIOH. IlpH oxocKonHH <J)H6po3Haa nacxb ceporo usexa, 6jiecxHx.
HeHaxanyxaa iacxb npeacxaBJiaex coSoii HeGojiburyio nacxb 6apa6aHHon nepenonKH, Koxopaa saHHMaex He6ojibmyio BbipesKy HHMCHero Kpaa qeuryH BHCOIHOH KOCXH
(incisura Rivini). 3xa lacn. nepenoHKH (pars flaccida, membrana Shrapnelli) HC
HMeex 4>H6p03Horo cjioa. BapaGaHHaa nepenoHKa BorHyra B cxopony 6apa6aHHOH
nojiocxH H KaK 6bi oGpasyex sopOHKy. Mecxo HaH6ojibmero BaaBJieHHa Haxoanxca
B uenxpe nepenoHKH H nasbiBaexca «nynoK» (umbo). B 3XOM Mecxe K nepenoHKe
Kpennxca pyKoaxKa MOJioxoiKa.
62
TeMa IV. VXO: CJ1YXOBOM AHAJ1M3ATOP
Cexb KpOBCHOCHbix cocyiiOB 6apa6aHHOH nepenoHKH MaKCHManbHO Bbipaacena na nepH(J>epHH, nocjeneHHO HcxoHnaact K uenxpy. B CBSBH c SXHM npH ocxpoM FHOHHOM BocnaneHHH cpe/iHero yxa, Kor^a rHOHHbiH 3KCcy,ziax CKaruiHBaexca
B 6apa6aHHOH HOJIOCXH, paspws (nep(J>opauHa) 6apa6aHHOH nepenoHKH HOCHX HC
KpaeBOH, a oGoflKOBbiH HJIH ueHXpajibHbiH xapaKxep.
^CTCKHC ocoGeiiHocTH 6apa6annon nepenoHKH. y HOBOpoayjenHbix H flexeH
rpyziHoro aospacxa TomuHHa smmepMajibHoro H CJIHSHCXOFO cnoa nepenoHKH 6ojn>uie, HCM y Bspocnbix. EapaGaHHaa nojiocxb HCBOSflyuma, BbinojiHena MHKCOHIIHOH
xKaubio. B CBasH c 3XHM nepeuoffica xycKJiaa, ne HMCCX xapaKxepnoro ww B3pocjn>ix
oxftuecKa. PacnojioaceHHe nepenoHKH npaKXHnecKH ropHsoirajibHoe, JTOJI naiaioHa K
OCH napyacHoro cnyxoBoro npoxofla cocxaBjwex OKOJIO 20°, HXO 3HaHHxejn>HO 3axpyflHaex ocMOxp. y aexefi ivtna^uiero aospacxa 6apa6aHHaa nepenoHKa Kpyrjiaa,
6jieflHo-po3OBoro usexa ro-sa o6miHa KpOBeHocHbix cocyaoB, Jienco Kpacueex npn
ruiane, HXO HC Hyacuo nyraxb c BOcnanHxenbHofi ranepeMHeH. Xopouiee KpoBocHaG»eHHe OTHocHxejibHO xojicxbix cjiocB 6apa6aHHOH nepenoHKH aBjwerca npenaxcxBHCM ana oSpasoBaHna nepij>opauHH npn ocxpoin FHOHHOM cpeflHCM oxnxe. B CBSSH c
3XHM y flereH Hepe^Ko xeqeHne rnoHHoro oxHra HMCCX Henep^opaxHBHbiii xapaKxep
H xpeoyex pacceneHHa 6apa6aHHoii nepenoHKH. y flexefi cxapmero sospacxa, KaK y
Bspooibix, 6apa6aHHaa nepenoHKa osajibHOH (JiopMbi, nepjiaMyxpoBO-ceporo usexa,
uoJiynpospaHHaa, xonmHHa ee He npeBbiuiaex 0,1 MM.
BnyxpeHHaa (MeflHajibHaa) crenKa 6apa6aHHOH UOJIOCXH HOCHX HasBaHHe
«na6HpHHXHaa», xaK KaK oxrpaHHHHsaex cpeanee yxo ox na6HpHHxa BHyxpeHHero
yxa. HHJKHHH saBHXOK ynnxKH Bbicxynaex B npocBer 6apa6aHHOH nonocxH B cepeflHHe ee MeanajibHOH CXCHKH, o6pa3ya MHC (promontorium). B CJIHSHCXOH 6apa6aHHOH nonocxH B oGnacxH Mbica pacnonaraexca Hepsnoe 6apa6anHoe cmiexeHHe (craiexeHHe ^Ko6coHa). B ero cocxaB BXO^SX BOJIOKHa V, VII, IX lepennbix
nepBOB, a xaKwe cHMnaxHHecKne BonoKOHa ox plexus caroticus interims. O^HaKo
6apa6aHHoe cnjiexeHHe oGpasyexca B OCHOBHOM sa CHCT 6apa6aHHoro nepaa (n.
tympanicus) — BCXBH asbiKoraoxoHHoro Hepsa, KoxopbiH no Bbixofle HS BHCOHHOH KOCXH uasbiBaexca ManbiM KaMenncxbiM nepBOM (n. petrosus minor). OH
ocymecxBJiaex csasb Meacay asbiKorjioxoHHHM nepBOM H yuiHbiM ysjioM V nepenHoro Hepsa. OosaflH, na CKJIOHC Mwca, HMeioxca ABC HHIIIH: ssepxy — HHiua
OBanbHoro OKHa, Be^ymero B npeAflsepHe jia6npHHTa, BHHsy — HHUia Kpyraoro
OKHa, Beaymero B yjiHTKy. B oaajibHOM OKHC KOJibueBH^HOH CBSSKOH Kpennxca
nofluoacuaa ruiacxHHKa cxpeMCHH. Bnaroaapa 3jiacxHHHOCXH KOJibueEHflHOH CBHSKH CXpCMS nOflBHHCHO B OBajIbHOM OKHC. KpyTJIOC OKHO 3aX«HyXO BXOpHHHOH
6a-
pa6aHHOH nepenoHKoft, Koxopaa ox^exwex 6apa6aHHyK> Jiecxunuy yjiHXKH ox 6apa6aHHOH HOUOCXH. Haa osajibHtiM OKHOM Bflonb MeflHanbHOH CXCHKH pacnonaraexca ropnsoHxajibHoe KOJICHO Kauana JiHuesoro nepsa (canalis Fallopii). Kanan
HaupaBjiaexca B anxpyM, r^e Ha BHyxpeHHCH CXCHKC auxpyMa y Bbicxyna ropnsoHxajibHoro nojiyKpyxnoro Kanana pesKO noBopannBaex BHHS — HHcxoflaiuee
KOJieuo — H BbixoflHT na OCHOBaHHe nepena nepea mnjiococueBH^Hoe oxBepcxne.
I. KnMHHMecKaa aHaroMuq cnyxoeoro aHannaaropa
63
B 6apa6aHHOH HOJIOCXH Bbmejiarox xpn otaejia (HUH sxaaca): BepxHHH —
3HHXHMnaHyM (axXHK), CpeflHHH
MCSOXHMnauyM, HH5KHHH
EapaSannaa nojiocxb coaepacHx xpn cjiyxoBbie KOCTOHKH — MOJIOXOHCK,
sajibHio H cxpeMa, Koxopbie CBsnaHH Me».zry coGofi cycxasaMH H oGpaayiox HCnpepbiBHyio uenb ox 6apa6aHHOH nepenoHKH flo OBanbHoro OKHa. CsasKaMH cjiyxoBbie KOCXOHKH Kpenaxca K cxeHKaM 6apa6aHHOH HOJIOCXH. PyKoaxKa MOJIOTOHKa BnjiexeHa B 4>H6po3HHH CJIOH 6apa6aHHOH nepenoHKH, noflHOHCHaa miacxHHKa
CTpeMCHH KpCUHXCa B OBajIbHOM OKHC.
<I>u3uojiozuHecKu ifenb cjiyxoebix KocmoneK npedcmaemem coSou 6uojiozuvecKuu aKycmutecKuu moan —pbiHOMCHbiu MexaHU3M, o6ecnemieaK>muu nepedavy ssyKoeou 3nepzuu us eo3dyumou cpedu e JKudKue cpedbi eHympennezoyxa 6es nomepb.
MOJIOXOHCK COCXOHX H3 ronoBKH, uicHKH, pyKoaxKH, nepe^Hero H jiaxepanbHoro oxpocxKOB. JlaxepajibHbiH oxpocxoK MonoxonKa BbinanHBaex 6apa6aHHyio
nepenoHKy B HeHaxaHyxofi nacxn H xopomo oSospHM npn OXOCKOHHH. HsMCHeHHC ero KOHxypOB npn oxocKonnn HMCCX 6ojibmoe snaHCHHe ana OUCHKH Bocnai npouecca B cpe^neM yxe.
: HMeex ase HO»CKH — KopoTKyro H anHHHyw, HeneBHueoSpaaHbiH
oxpocxoK H xejio c cycxaBHOH noBepxHocxbro ana FOJIOBKH MonoxoHKa. KopoxKaa
HOHCKa saxoflHx BO Bxofl B aHxpyM H MO3Kex 6wxb noBpe»fleHa npn Heocxopo^cHHX HHCxpyMeHxajibHbix MaHHnyjiauHax, npn XHpypmHCCKOM BMeuiaxejibcxae (a
c HBH BMCCXC nocxpaflaex H aca uenb cnyxoBbix KOCXOHCK). HeneBHueoGpasHbiH
oxpocxoK caasan cycxaBOM c TOJIOBKOH cxpeMeHH. Teno HaKOBajibHH, ronoBKa H
UieHKa MOJIOXOHK3 paCnOJIOXCCHbl B aXXHKC.
B cxpoeHHH cxpeMeHH pasnnnaiox rojiosKy, nepe^Hioio H aajHioio HOXCKH H
OCHOB3.HHC (^nO^HOHCHSH IIJ13.CTHHK3.J.
Cycxasbi Me>Kfly cnyxoBbiMH KOCXOHKaMH coflep»ax MeHHCKH. IIpH upoxoxcfleHHH BByKOBbix KOJie6aHHH npoHCxoflax cjio5KHbie nepeMCiucHHa KOCXOHCK.
K ronoBKe cxpeMeHH Kpennxca cyxoxcHJine CXPCMCHHOH MHIUUH (m. stapedius),
cyxoxcHJiHe c flpyron cxoponw Haxoanxca B KOCXHOM BJiarajinme y Bxoaa B nemepy. 3xa Mbiuiua yaepWHBaex cjiyxoBbie KOCXOHKH B cocxoaHHH nanpa^ceHHa,
HanGonee 6jiaronpHaxHoro fljia nposeaeHHa sayKa. K uicHKe MOJioxoHKa Kpennxca cyxoacHJine Mbiiuubi, HaxarHBaioiueH 6apa6aHHyio nepenoHKy (m. tensor
tympani), Koxopoe nepeSpacbiBaexca noa yraoM nepes yjinxKOBbin oxpocxoK na
MeflHajibHOH CXCHKC 6apa6aHHOH nojiocxn. Hanajio CBOC Mbiuiua 6epex OKOJIO
ycxba cjiyxoBOH xpy6w. O6e Mbiiuubi peryjinpyiox cxeneHb noflBHacuocra cjiyxoBMX KOCXOHCK, oGecneHHBaa aKKOMOflaunio (nanpHMep, npn npncjiyiuHBaHKH) H
samnxy (BO speww 3ByKOB 6ojibuioH HnxencHBHOCxH BO3HHKaeT xexaHHHecKoe
coKpameHHe SXHX Mbium). CxpeMCHHaa Mbiuiua HHHepBHpyexca BexBbio JIHUCBOro nepsa (n. stapedius), a Mtiuiua, HaxarHBaiomaa 6apa6aHHyio nepenoHKy, —
BexBbio xpoHHHHHoro Hepsa HS yuiHoro ysjia.
64
Teiwa IV. YXO: CJIYXOBOM AHAJ1M3ATOP
Bapa6aHHaa nojiocxb Bbicrjiana CJIHSHCXOH OGOJIOHKOH, npeacxaBJiaiomeH
CQ6OH OJIHOCJIOHHblH IUIOCKHH SIIHXeJIHH C HCMHOrOHHCJieHHblMH 60KajIOBHJIHbI-
. CjiH3Hcxaa oSonoHKa ILIIOXHO npHMbiKaex K KOCXHWM cxeHKaM, He
s. Y HOBopoacfleHHbix noHXH Becb npocBex 6apa6aHHOH nonocxH
BblHOJIHek MHRCOH^HOH XK3HbK) (HCSpCJiaa 3M6pHOHajIbH3a XK3Hb). 3x3 XK3Hb B
6ojIbUIOM KOJIHHCCXBe COflCpJKHX MyUHH, KOXOpblH aBJiaCXCa OHXaxeJIbHOH CpeflOH
flJia 6aKXepHH. I103XOMy npH HH(j)HUHpOBaHHH CpCflHCrO yxa MHKCOHflH3a XK3Hb
Moacex cxaxb IIPHHHHOH moHHoro cpeflnero OTHxa. SaaepacKa pe3Op6u,HH MHKCOHflHOH XK3HH npH o6lU,eH HC3peJIOCXH HMMyHHOH CHCXCMbl B yCJIOBHflX M3CCHB-
HOH 6aKxepH3JibHOH o6ceMeHCHHocxH aBJiaexca HPHHHHOH peinmHBHpyiomero
rHOHHoro cpeflnero oxnxa y rpyflHbix flexen.
CjiH3HCxaa o6ojioiKa co CXCHOK nepexoflHx na uem> oryxoBbix KOCXOHCK, 06pasya pun cKJia^oK (KapMaeoB). TaKHM oGpasoM B 6apa6aHHOH HOJIOCXH oSpasyroxca «y3KHe Mecxa», Koxopbie anoxo apeHnpyioxca npH BocnajienHH H cnoco6cxByrox nepCHCxeHUHH HH^CKUHH B nojiocxax cpe^Hero yxa. Hpn
BMcuisxejibcxBax B 6apa6aHHoii DOJIOCXH SXH KapMaHH
PCBHSHH, X3K K3K MOFyX B flaJIbHCHIIieM CJty»HXb npHHHHOH pCUHflHBa
KOCXH HUH xojiecxeaxoMbi.
CjiyxoBaa xpy6a (EBcxaxneBa xpy6a) coe^HHaex nonocxH cpeflHero yxa c HOcorjioxKofi. /ijiHHa ee flocxHraex y Bspocjibix 3,5 CM. OHSHOjiorHnecKHe 4>yHKUHH
xpy6w — flpenaHCHaa, BeHXHJiauHOHHaa H samHraaa. B cjiyxosoH xpy6e pasjinnaiox Kocxnyio nacxb, pacnojioaceHHyro y 6apa63HHoro ycxba, &JIHHOH OKOJIO
1 CM, H nepenoHiaxo-xpaujeByio nacxt — y raoxoHHoro ycxba, OTHHOH OKOJIO
2,5 CM. HaH6ojiee ysKHH npocaex xpy6w B sone ee nepeuieiiKa — na rpaHHue KOCXHOH H nepenoHHaxo-xpamesoH qacxefi — OKOJIO 3 MM. EtpocBex xpy6bi B KOCXHOH nacxH — OKOJIO 3-5 MM, B nepenoHiaxo-xpameBOH — 5-9 MM. Bbicxjiana
cjiyxosaa xpy6a qHJiHHflpHHecKHM MepqsxejibHbiM SOHXCJIHCM. PCCHHHKH SHHTCJina flBH3Kyxca B cxopony HOCOFJIOXKH. B cocxoaHHH noKoa CXCHKH cjiyxoBOH
xpy6w B o6jiacxH nepemeHKa npnjiexcax apyr K apyry — xpy6a saiqpbixa. Hpn
rjioxaxejibHbix flBH»ceHHax, seBaHHH CTCHKH xpy6w oxicpbisaioxca, H Bosjryx nocxynaex B 6apa6aHHyio nojiocxb. TjioxoiHoe ycxbe cjiyxosoH xpy6u pacnojioxceHO H3 6OKOBOH CXCHKC HOCOFJIOXKH H3 ypOBHC 33flHCrO KOHU3 HH3CHHX HOCOBblX
paKOBHH. y flexefi rpyflHoro B03p3cx3 CjiyxoBaa xpy6a uinpe, ICM y BspocJibix,
pacnojioHcena ropHSOHxajibHee. 3xo o6ycjioBjiHBaex nonsaaHHe coaepacHMoro
>KejiyflKa B cjxyxoByjo xpy6y H 6apa6aHHyK> nojiocxb npn cpbiraBanHH nocjie
KOpMJieHHa B ropnsoHxajibHOM nojio»ceHHH pe6enKa. ynaxbiBaa aaHHoe o6cxoaxejibcxBO, neflHaxpbi peKOMenayiox poflnxejwM npoBoanxb KopMJienHe peGeHKa c
npnnoflHaxoH FOJIOBOH, 3 nocjie KopMJienHa yaepacHB3Xb pe6eHK3 B
HOM nOJIOKCHHH flO OKOHHSHHa CpbirHB3HHa. V fleXBH flOUIKOJIbHOrO H
uiKOJibHoro Bospacxa rjioxoHHoe ycxbe cjiyxoBOH xpy6bi nepeflKO KOHxaicrnpyex c
paspacx3HHaMH FJIOXOHHOH MHHflajiHHbi (aaenoHjibi), HXO o6ycjioBjiHBaex HH<J>HUHpoB3HHe 63pa6aHHOH nojiocxH pHHoreHHbiM nyxeM npn
65
I. KnuHMMecKan aHaxownn cnyxoaoro aHannaaxopa
CoCHCBHflHblH OXpOCXOK SaKJHOHaCX B Ce6e MHOHCCCXBO MCJIKHX nOJIOCXCH
KJiexoK, Koxopwe coeflHHCHbi Me»my co6ofi H BbicxjiaHbi CJIHSHCXOH o6ojiOHKOH,
aBJiaromeHca npoaoJiHceHHCM CJIHSHCXOH 6apa6anHOH HOJIOCXH. B saBHCHMOcxH
ox sejiHHHHbi H KOJiHHecxBa KJiexoK Bbiflejwiox cjiejiyiomHe XHHH cxpoeHHa cocUCBH^HblX OXpOCXKOB:
1. HHeBMaxHHecKHH xnn — npeflcxaBJien 6ojibuiHM KOJIHHCCXBOM BosayxoHOCHblX KJieXOK. IlpH SHaiHXeJIbHOH nHCBMaXHSaUHH aHCHKH COCUCBHflHOrO OX-
pocxKa Moryx pacnpocxpaiwxbca na see ox^ejiw BHCOHHOH KOCXH — pars
squamosa, pars petrosa, pars tympanica, a xaioKe na CKyjiOByio Kocxb.
2. ,II,HiiJi03XHHecKHH XHn — cociieBHflHbifi oxpocxoK COCXOHX H3 ry6Maxoro
KOCXHOFO BemecxBa H HesHannxejibHoro KOJinHecxsa KJICXOK OKOJIO anxpyMa.
3. CKJiepOXHHeCKHH XHH
COCUeBHflHMH OXpOCXOK
COCXOHX H3 FIJIOXHOH
KOMnaKXHoK KOCXH H He coflep»Hx KJiexoK H ry6naxoro KOCXHOFO BemecxBa.
CaMaa KpynHaa, e^HHCXBeHHaa KJiexKa, HMeromaaca B cocqeBHflHOM oxpocxKe
jno6oro xnna — nemepa (antrum). Y Bspocjiwx anxpyM pacnono»ceH B xojime cocueBHWHoro oxpocxKa na rjiyGnne OKOJIO 2-3 CM ox ero HapyxcnoH noBepxHOCxH.
AnxpyM cooGmaexca c 6apa6aHHofi nojiocxbio UIHPOKHM coycxbeM (aditus ad
antrum) na saflHen CXCHKC 6apa6aHHOH FIOJIOCXH. Y rpyflHbix flexeft, Koraa cocueBHflHbiH oxpocxoK npaKXHHecKH eme oxcyxcxByex, anxpyM xaicace Bceraa HMeexca,
HO, B OXJIHHH6 OX BSpOCJIblX, paCHOJIOHCCH nOBCpXHOCXHO, HenOCpeflCXBCHHO nOA
Hapy^CHOH KOCXHOH IIJiaCXHHKOH. Ha BHyipeHHCH nOBCpXHOCXH COCUCBHflHOrO OX-
pocxKa HMeexca acejioGosaxoe yrny6jieHHe, B KoxopoM npoxo^Hx CHTMOBH^HbiH
CHHyC, OXBOAaUIHH BCHOSHyiO KpOBb H3 M03Fa B JiyKOBHUy BHyrpeHHCH apeMHOH
BCHbi. Ha BepuiHHe oxpocxKa HMeexca rjry6oKaa Goposaa, nepes Koxopyro npn BOCnaneHHH cociieBH^Horo oxpocxKa FHOH HHor^a npopbisaexca no^ Mbiuiirbi IHCH.
Tpenanatfwo coctfeeudnozo ompocmKa odbmno npoeodum «,#,«.*_,
e npedejiax mpeyzojibnuKa LUuno, zpanutfOMU
Komopozo _AA.,O <,-«* ; 0i>
— ceepxy — eucoHnaa JIUHWI, npodojwcenue CKynoeou dyzu;
— cnepedu — npsiMan., npoeedeman nepes sadnuu Kpau
napyoicHozo c/iyxoeozo npoxoda c Hoxodnuieucfi na HCM
ocmbJO (spina supra-meatum), do eepxyuiKu coctfeeudnozo
ompocmKa;
— csadu — coctfeeudhbiu zpedeiuoK.
xonorpa^HHecKOH 6jiH3ocxn jiHueBoro nepaa K o6pa3OB3HHaM
BHCOIHOH KOCXH uejiecoo6pa3HO npocjie^HXb ero xo^. JlnueBOH Heps (VII) BWxoflHX H3 cxBOJia Mosra B o6nacxH MOCxo-MosxceHKOBoro yrji3 BMecxe c n. intermedius (XIII, n. Wrisbergi) H n. vestibulocochlesris (VIII) H EXO^HX BO BHyxpeHHHH CJiyXOBOH HpOXOfl nHp3MH/JbI BHCOHHOH KOCXH. B OCHOB3HHH BHyXpCHHerO
cjiyxoBoro npoxoas VII H XIII nepBH oxxo^ax ox cjiyxosoro nepsa H axo^ax B
K3Han jiHiicBoro HepBa (OajuionHCB KaHaji). B Mecxe KOJieHiaxoro H3rn6a sxoro
66
Tewa IV. YXO: CJIYXOBOI/I AHAJ1H3ATOP
Puc. 14. YIIIHOH jia6HpHHr:
1 — yjiHTKa, 2 — npeansepHe,
3 — OBaiibHoe OKHO, 4 — Kpynioe OKHO,
5 — nepeflHHft noJiyKpyacnbifi Kanaji,
6 — saaHHH nojiyKpyscHbiH Kanaji,
7 — jiaTepajitHtra nojiyKpymiWH Kanair
KaHana JIHUCBOH nepa yrojimaerca 3a CHCT KOJieHHaTOro ysjia (ganglion geniculi). 3roT ysen
HOFO OKHa npe&HBepHa ^o rejiHKOTpeMbi, a
6apa6aHHaa JiecraHua — OT Kpyraoro OKHa
OTHOCHTCa K HyBCTBHTCJIbHOH HaCTH npOMCacy-
flO rejIHKOTpCMbl.
TOHHoro Hepsa. Ilpoxofla nepea Tojmry KOCTH,
KaHaji jiHiieBoro nepsa flocrHraer Me^HajibHOH
CTCHKH 6apa6aHHOH OOJIOCTH, r^e nofl npaMbiM
yrjioM noBOpaHHBaer raa/m (nepsoe KoneHue).
KocTHbiH Kanaji Hepaa pacnojioacen naa osajibHWM OKHOM. HHoiTja CTCHKH Kanajia HMCIOT anH CO CTOpOHH 6apa6aHHOH HOJIOCTH
TOJibKO CJIHSHCTOH o6ojiOHKOH. B
CBS3H C 3THM npH FHOHHOM BOCnajICHHH CpeflHC-
ro yxa Moacer Ha6jnoflaTbca ororeHHbiH napes
jDmesoro Hepsa. Ha ypOBne Bxofla B nemqjy
Heps B CBOCM KOCTHOM KaHane Kpyro noBopaHHBaeT BHH3 (flTopoe KOJieHue), npoxo/nrr
TOJimy KOCTH H BbixoflHT Ha ocHOBaHHC Hcpena nepes iimjiococueBHflHoe OTBqxnue,
npoHHKaer B Torauy OKOJtoyuiHOH CJITOHOH xcenesbi, pasaeaiaacb na pag KOHCHHbix BCTBCH, HHHepBHpyiouiHX MHMHHecKyK) MyCKyjiaTypy.
BnyrpeHHe yxo (yiimon jia6npHHT) noapasflejwioT na yjnrncy —
jiaGnpHHT, npejWBepHe H CHCTCMy nojiyKpyacnbix KanajiOB —
YUIHOH jiaGnpHHT cnapyacH npeflCTaBJien KOCTHHMH CTpyKTypaMH, xofl KOTOPMX
H3HyrpH HOBTOpaeT nepenoHnaTbiH Jia6HpHHT (pnc. 14). YjiHTKa OTHOCHTCa K nepeuenropy cjryxoBoro anajiHsaTopa. IlpeMBepHe jia6npHHTa H
Kanajibi cojjepacaT B ce6e nepH(J)epHHecKHe peuenTOpw
jiapnoro
(cochlea) npe/jCTaBJiaeT co6oH KOCTHyro cnnpanb B 2,5 saBHTKa BOnpyr KOCTHOFO CTepacna (modiolus). Ha nonepeHHOM cpese B Kasiy;oM saBHTKe
ipn OTflena: JiecTHHuy npeaaBepHa, 6apa6aHHyio H cpeflHHHyro JIBCT(PHC. 15). CnHpanbHbiH Kanan yjiHTKH nacTHHHO pasflenen no BCCMy fljinnTOHKOH KOCTHOH cnHpajibHofi njiacTHHKOH, OTxoflameH OT modiolus (lamina
spiralis ossea). Ee npoflOjmaeT ao napy)KHOH KOCTHOH CTCHKH yjiHTKH ocnoBHaa
MCM6pana (membrana basilaris), KOTOpaa KpenHTca K napyacHOH CTCHKC yjiHTKH
cnnpajibHOH CBS3KOH. CnnpajibHaa csasKa Taicace nojmep>KHBaeT cocyAHCiyio nojiocKy. KopTHCB opraH (cnnpajibHUH opran, cnyxoBOH peqenTOp) — nepH(})epHHCCKHH peqenTOp cjiyxoBoro anajiHsaTopa — pacnojioscen na Gojibuieft iacTH
SH^OUHMCjiaTHHeCKOH nOBCpXHOCTH OCHOBHOH MCM6paHbI.
TaKHM o6pa3OM, Kanaji yjiHTKH pasflenaerca na JICCTHHUW Ha BCCM npoTa^ceHHH, sa HCKjuoHCHHeM MajieHbKoro OTBepcTHa y BepxyuiKH yjiHTKH, HasbiBaeMoro
. JlecTHHua npeOTBepna (scala vestibuli) npocTHpaerca OT
67
I. KriMHimecKafl aHaioMUFi cnyxoeoro aHannaaropa
7
Or KOCTHOH CnnpajibHOH IIJiaCTHHKH KBCpXy
B flHaroHanbHOM HanpaBJieHHH orxoflnr Tomcaa
PeftccHepoBa MeMGpana, KOTopaa npHKpenjiaerca K HapyacHOH CTCHKC yjmrKH Bbiiue OCHOBHOH
4>opMHpya cpeflHHHyio Jiecnnmy
ynHTKOBbiH xofl (ductus cochlearis). PeHCCHepoaa MCMGpana npocTnpaeTca flo
rejiHKOTpeMbi, rae coeflHHaeTca c OCHOBHOH
MCM6paHOH. Bapa6aHHaa JiecTHHua H JICCTHHua npeOTBepHa co^epacaT nepHJiHM^y —
»CHflKOCTb, no
HOHHOMy COCTaBy COOTBCTCT-
Puc. 15. VJIHTKE:
1 — jieciHHua npeaasepna,
2 — cpeaHHHas JiecTHHua (ynHTKOBufi
xofl), 3 — 6apa6aHHaa jiecTHHiia,
4 — PeflccHepoBa MeMBpana,
5 — KopTHCB opran, 6 — KOCTHIJH Kasyiomyio BHeKJieroHHOH H ciuiHHOMOsroBOH
naji y^HTKH, 7 — cirapajibHtiH ranr. Bapa6amiaa Jiecnniua nocpeacTBOM
JIHH, 8 — BOJioKHa cjiyxoBoro nepsa
yjiHTKH coeflHHCHa c cy6apaxHonnpocrpaHCTBOM saaHefi HepennoH aMKH. ^&vjKOcrb yjiHTKOBoro
— H3oocMOTHHHa nepHJiHM<J>e, HO oTJiHHaerca OT nee no HOHHOMy cocraBy. B 3Hao;iHM(J)e coflepaorrca MHOFO HOHOB Kanna H MBJIO HOHOB HarpHa, HTO coOTBeTCTByeT BHyipHKJieTOHHOH aCHflKOCTH. Pe3Op6ujW 3HflOJIHM$aTHMeCKOH
CTH npOHCXOflHT B 3HflOJIHM(J)aTHHeCKOM MCEIKe H3 SaflHCH HOBepXHOCTH
BHCOHHOH KOCTH, Kyfla OH3 nocTynaer nepes BO^onpoBO^ npe
pasjBWHoro cocrasa aamKocrefi BHyrpeHHero yxa o6ecneHHBaerca HajiHMHCM B
M6M6paHO3HOM JiaGnpHHTC 3nHTejIH3JIbHbIX OIiaCTOB, HMCIOmHX MHOaCCCTBO nJIOT-
Hbix repMeraraHbix coe^HHeKHH. HapyiueHne HOHHOFO cocrasa 3Hflo- H nepHJiHM4>bi
K yrpaTe cnyxoBOH (JiyHKUjiH, nocKOjaicy KopraeB opraHjie^HMeeT CBOHX.CQT
a ero nnraHHe ocymecTBJiaerca cocyflHCTOH nojiocKOH yjiHTKOBoro xoaa
oBOCHaoaceHHe BHyrpeHHero yxa ocymecrBJiKerca
jia6HpHHTHOH apTepneH. OcoGeHHOcrb STOTO apTCpnajibHoro CTBOJia B TOM, HTO OH HC HMeer auacxoMOSOB. HosxoMy jno6aa naxojioraa, npHBOflamaa K Hapyiueinno KpOBOTOKa B Bepre6po6a3HjwpHOM 6acceHHC, Taicace
Moacex npHBOflHXb K napyuieHHio 4>yHKUHH KoprHCBoro oprana.
FoMeocTas BHyrpeHHHx naGnpHHTHbix cpe^ saBHCHT OT 4)yHKUHOHajibHoro
cocToaHHa reMaTOJiaGnpHHTHoro Gapbepa. CTaGnjibHOCTb 3Toro rHCTo-reMaranecKoro Gapbepa BwcoKa: OH coxpaHaer HHepTHOCTb npn BwpaaceHHbix oGmnx
paccxpoHCTBax reMOflHHaMHKH, asjiaexca nperpafloft fljix jieKapcxBCHHbix npenapaxoB, MHOFHX 6aKTepHH H TOKCHHOB. TeM He Menee, oTAenbHwe jieKapcxBenHbie
npenapaxbi (aMHHoraHKOSHflbi, neKoxopbie .wypexHKH) H xoKCHnecKHe BemecTBa
(nepeaKO coflepacaiuneca B cypporaTax anKorona), a TaKace HCKOTOpue BHpycbi
(rpnnn) Moryr ceneKTHBHO HapymaTb npoHHuaeMOCTb
Sapbepa H BbisuBaTb KyMyjiaxHBHbiH XOKCHHCCKHH 34><J>eKx.
68
Tewa IV. YXO: CJIVXOBOU AHAJ1M3ATOP
II. OH3MOJlOrHfl CJlYXOBOrO AHAJ1M3ATOPA
,B(jiH noHHMaHHH (JiHSHOnorHH cjryxoBoro aHajiHsaxopa Heo6xojjHMO HOBTOpHXb H3 Kypca (}>H3HKH CpeflHCH HIKOJIH MCXaHHKy H aKyCXHKy, B HaCTHOCXH
xapaicxepHCXHKy ssyKOBOH BOJIHH, pesonanc, pbinaxcHbie MexaHHSMH, noHaxne
rpajmeHxa, HMne/iaHca.
OCHOBHOH <J)yHKUHfl yjurxKH H npe^uiecxByioiiuix CH anaxoMHHecKHX cxpyKxyp— BocnpHflTHe H nepBHMHtra aHanH3 3ByKa. Opran cnyxa HMeer CJIOHCHHH
BcnoMoraxenbHbiH annapax, o6ecne4HBaK>iHHH npOBejjeHHe H ycHJiemie ssyKOBHX
CHiuajiOB BHeiiiHeH cpeflbi. BByKonpoBOflaiime aHaxoMHHCCKHe cxpyicrypbi Hapyacnoro, cpe/piero yxa, aomKOCXH BHyrpeHHero yxa H GasurapHaa MeMopana, a xaioice caM
nepHtJiepHHecKHH peuenxop (KopxHCB opran) oiHocarca K nepn^epHHecKOMy oxaeny
cjiyxoBoro anajiHsaxopa. npOBoanmcoBbie BocxoaaiuHH H HHCxoflauom cnyxoBwe
nyiH, noflKopKOBbie a^pa H KopKOBtie uempbi cjxyxa oxnocarca K ueHxpajibHOMy oxflejiy cjiyxoBoro anajiHsaxopa. nepH(j)epH4ecKHH oxaeji, B CBOK> onepeflb,flejiHXCHna
3ByKonpOBOflHiUHH (HapyacHoe, cpe;jHee yxo, HCHWKOCXH H 6a3HJiapHaa MeMGpana
BHyrpeHHero yxa) H sfiyKOBocnpHHHMaiomHH (KopraeB opraH) oxflejibi.
HapysKHoe yxo. YuiHaa paKOBHHa npeflcxaBJwex co6oH JiHHeHHHH (J)HJibxp,
npeoSpasyiomnfi npocxpaHCXBCHHwe npH3HaKH sByKOBoro nojia BO BpeMCHHbie.
Oco5oe HsSHpaxejibHoe SHanenHe yuinaa paKOBpma npnoGpexaex npH MOHoaypajibHOH cnocoGnocTH jiOKaiiHSOBaxb 3ByKH B BepTHKanbHOH nnocKocxH, xaicace yinnaa
paKOBHHa BJinaex na cnoco6HOcn> pasjiH^aTb ssyKOBbie CHTHajibi cnepe^H H csajin
rojiOBbi. B HapyamoM cjiyxoBOM npoxoge ana sayKOBbix BOJIH Hacxoxoft OKOJIO 3 icTu
npoHcxoflHx ycHJieHHe ssyKOBoroflaBJieHHfly 6apa6aHHOH nepenoHKH na 10-12 aB,
4x0 oStflCHaexcfl pesonaHCHbiMH CBoncxBaMH xpyGicn AJIHHOH 2,5-2,7 CM. HH3Kaa
»cecTKOCTi> CTCHOK Hapyaoioro cjiyxoBoro npoxoaa cnoco6crByex ManoMy oxpaaceHHK) H 6ojn>moMy noraomeHHw ssyKOBbix BOJIH ^pyrax nacroT. TaKHM oGpasoM, B
napyacHOM yxe npOHCxo^Hx H36HpaxejibHoe ycancHHe ssyKOBbix CHimjioB.
CpeflHee yxo. Ilo saKOHaM aKycxmcH asyKOBbie BOJIHH oxpajKaioxcH ox noBepxHOcxH cpea, HMeromnx pasnoe aKycxmecicoe conpoxHBJieHHe. IlocKOJibKy
aKycxHHecKoe conpoxHBJieHHe Bos^yxa B 4000 pas Menbuie conpoxHEjiemw XKRKOCXCH BHyrpeHHero yxa, nepejjana sByKosoro cnrnajia HS OKpyacaiomeH cpeflbi K
xcHflKocxflM BHyxpeHHero yxa BOSMOwna XOJU>KO c Gojibuiofl noxepeft SHepnra
(B cpeflHCM — 99,9 %). Bapa6aHHaa nepenoHKa H pbiHaxcnaa CHCxeMa cjiyxoBbix
KOCXO46K KOMHCHCHpyeX pa3JIHHHfl
aKyCXHHCCKOrO COnpOXHBJICHHa BOSflyxa H
»CHAKOH cpe/iH BHyxpeHHero yxa, HO c pasHOH s^K^eKTHBHOcxbio WM BOJIH pasnbix
nacxoT. Menee Bcero oxpamaroTca BOJIHH lacxoxofi SOO-lSOOTu. MexanHHecKaa
pbwaacHaa CHCxeMa KOCXOHCK cpeanero yxa npH nepeaane ssyxa ox 6apa6aHHOH
nepenoHKH K noflHO»(HOH miacxHHKe cxpeMCHH ycHJiHBaex SBJTC B 1,3 pasa.
B nepeaane ssyxa yqacxByex HC BCH noBepxHocxb 6apa6aHHOH nepenoHKH, a xojn,KO ee lacxb OKOJIO pyKoaxKH MOJioxoHKa imomaflbio 0,66 CM2, Kpacsaa nacrb 6apa6anHOH nepenoHKH mpaex pom. 3Kpana AIM Kpyraoro OKHa. rLnomam. HO^HOWHOH njia-
II. cDnanonorun cnyxosoro aHa/iMsaxopa
69
CXHHKH cxpeMCHH — 0,032 CM2. EfocKOJibKy CHjia fleHCTBHa BOJiHbi nponopuHOHajibHa
ee flaBJieHHK), yMHOXceHHOMy Ha KOHraKTHpyiomyK) njiomaflb, TO pasHHLja 4>yHKUHOHajn.HO-3(}>4>eKTHBHOH imomaflH 6apa6aHHOH nepenomai H ocHOBaHHH crpeMCHH TSKyKe npHBOflHx K ycHJienmo zjaBJieHHfl sayKa Ha noflHOHaryio njiacxrancy cxpeMeHH. B
UCJIOM, CHCxeMa «6apa6aHHaa nepenoHKa — uenb cjiyxoBbix KOCXOHCIO) ycHJDmaex
flaBJICHHe SByKOBOH BOJIHH H3 HOAHO5KHyK) nJiaCTHHKy CTpeMCHH HpHMCpHO B 22 p333
no cpaBHemno cflaBjieHHCM,OKasbmacMbiM na 6apa6aHHyio nepenomcy (25-30 ^B).
PesonaHCHbie CBOHCTBa Bos^yxonocHbix aneeK cocueBHflHoro orpocxKa xaicace cnoco6cxByrox ycHJieHHK) ssyKa na 10-20flB. TaKHM o6pa3OM, o6mee ycHJiemie SBysa npn
ero npOBeaeHHH nepes napy»CHoe H cpe^Hee yxoflOCTHraex35-40 flB.
CjiyxoBOH ananasoH HejiOBenecKoro yxa — ox 16flo 20000Fu. B npnpoAe
cymecTByer orpOMHoe MnoacecTBo HCHBOTHHX, cnocoGnbix cjibiuiaTb HH(J)pa3ByKH H
yjiKipasByKH. HanpHMep, MOpCKaa Meaysa cnocoGHa BOcnpHHHMaib 3ByKH nacxoXOH 4-8 fu, HXO nosBOJwex eft ysnaxb o HaflBHraromeMca uixopMe sa 10-12 4acos
30 ero npHxofla B MBCXO ee HaxoaqjeHHa, a Jiexynne MHIIIH c noMombio yjibxpasByKOBbix BOJIH opHCHXHpyiox CBoft nojiex. HeJioBe4ecKoe yxo HanGojiee 4yBCTBHxejibHO K SBjrcaM nacTOTOH 1000-4000 Fi;. ^CnBaa pe^b BOcnpHHHMaexca B ananasoHe
500-4000 FlJ. K HH3KO4aCTOTHbIM 3ByK3M yXO 46JIOBeKa B MHJ1JIHOH p33 MCHCe
4yBcxBHxejibHO H juw HX BocnpHaxHa xpe6yexcfl ycHJieHHe, Koxopoe flocxHraexca B
nepH(J)epH4ecKOM ox^ejie cjiyxoaoro aHannsaxopa. BOJIHM HHSKHX H BHCOKHX 4acXOX oQjiaflaiOX paSHOH HHXeHCHBHOCTbK) H, B H3BeCTHOH MCpC, (J)yHKUHIO «BHpaB-
HHBaHHa rpOMKOCTH» HJIH a^anTauHK) K ssyKaM pasHofi HHTCHCHBHOCTH 6epCT Ha
ce6a Mbiiue4HHH annapaT 6apa6aHHOH HOJIOCTH. BMCCTC c TCM BosHHKarox cnxyaUHH, Korfla na yxo BOsaeftcxByioT 3ByicH npesBbPiaHHO Gojibuion HHXCHCHBHOCXH
(nanpHMep, npn Bspbisax), H xor^a xpeSyexca HX ocjiaGneHne, npn neflocxaxo4HOCXH KOMnencaxopHHx MexaHHSMOB BO3HHKaex anycxKHecKaa xpaBMa. Samnxnyio
<j}yHKU,HK> xaioKe BbinojiHaex MHUICHHUH annapax 6apa6aHHofi HOJIOCTH.
IlpH HSMCHCHKH 3TMOC(J)epHOrO flaBJICHHH B03HHK3eX paSHHUa aaBJICHHH HO
o6e cxopOHH 6apa6aHHOH nepenoHKH, 4x0 HCKa)Kaex npouecc ssyKonpoBefleHHa.
bipaBHHBaHHa flaBJieHHa BbinojiH^ex cJiyxoBaa xpy6a. ^46HKH cocueoxpocxKa xajcace asjiaroxca npeccopHHM 6y4>epoM H ynacxByiox B noflnocxoaHHoro /lasjieHHa B 6apa6aHHoft nojiocxn. B csasn c SXHM ana
cxa6HJibHOCXH flasjieHHa BHyxpn 6apa6aHHOH HOJIOCXH HMCCX 3Ha4CHHe xnn
cxpoeHHa cocueBHAHoro oxpocxKa. TaK, cpeanee yxo co ciciepoxH4ecKHM cocueBHflHHM OXpOCXKOM 60JICC CKJIOHHO K paSBHXHK) OXpHUaxeJIbHOFO raSOBOFO
6a-
jianca, a cjieaoaaxejibHO, — K nepCHCxenuHH BocnajinxejibHoro npoijecca.
BHyrpeHHee yxo. K co>KajieHHio, GnoMexaHHica yjiHXKH ^o CHX nop OKOH4axejibHO HCH3BecxHa. Hs anaxoMHH sByKOBOcnpHHHMaiomero annapaxa MO>KHO cflejiaxb BHBOfl, 4x0 cjryx peajiHsyexca nocpeacxBOM 4>n3HKo-xHMH^ecKHx, GHOXHMH4CCKHX H 3JieKXpH4CCKHX npOUeCCOB, HO nOHHMaHHC SaKOHOMCpHOCXH XpaHC(j)Op-
MatuiH SHeprHH SByKOBOH BOJIHH B sjieKxpHHecKHH HMiryjibc H peannsauHH peuenU.HH ssyKOBbix pasapaMCHTejieH BO BCCH mnpoxe STOTO noHaTna ocTaerca na ypOBHe
70
Tewa IV. YXO: CJIYXOBOM AHATIM3ATOP
BbinBH3KeHHa o6ocHOBaHHbix FHHOTes. HH oflna H3 npe&iKmeHHbix K HacxoameMy
BpeMCHH xeopHH cnyxa HC oxBenaex nojinocxbio na BCC BO3HHKaK>m,He Bonpocbi.
B CBflSH C 3THM HHXepCCHO npOCJICflHXb HOIIblTKy HCJIOBeHCCXBa OXBCXHXb H3 BO-
npoc «KaK MH cnbiuiHM?» Ha OCHOBC HanSoJiee o6ocHOB3HHbix rnnoxes CJiyxa.
IlepBbie ynoMHHaiQM o cjryxoBOH 4>yHKUHH HaiweHbi B xpyjjax flpeBHerpenecKHX
yneHbix. riH4)arop 3a 575 Jiex 40 HanieH spbi H AnaKcarop OKOJIO 100 Jiex cnycxa npeflJKBKHJIH nepBbie xeopHH cnyxa. HanGojiee HOJIHO 3TH xeopHH Gbura c4>opMyjfflpOBaHbi
,/JeMOKpHTOM H3 A6nepbi, KoxopbiH CHHxaji, HTO 3ByKH Bbi3bmaK)x BH6pauHK> BO3#yx3,
Haxoflameroca B yxe. 3ra BH6p3UHa saxeM nepeaaexca B Mosr c noMombio KDOBH H neHCHH. IlpH BCCH aOCypflHOCTH, C XOHKH 3pCHHa COBpeMCHHOH MC^HUJDn,!, 3X3 XCOpHa
snepBbie aana onpenejieHHe 3ByKy. CpaBmrre npa onpeaejieHHa noHania «3ByK», MOKay KOxopbiMH pasmma B 2,5 TbicaHH JICT: npeBHee «3ByK — BH6paiwa BO3nyx3» H coBpeMCHHoe «3ByK — KOJieoarejibHbie ABEDKemia nacnm ynpyroH cpeabi, pacnpocrpaKouomHeca B BHae BOJIH». ^anbHeiniraH mar snepefl cnejian THnnoKpax. OH nojiaraji,
HTO 3ByKH B nojiocxb q)eflHero yxa nepeaaex 6apa6aHHaa nepenomca. SsyicH, aBJiaioumeca «6ec4>opMeHHbiMH» npOHHKaiox nepes nepenoHKy B cpe;mee yxo H aauee —
nepes Manera.KHe OTBepcraa — K MO3it)BbiM o6oJiOHKaM, B HacrHocra, K naynmHOH.
Us aearejieH Mejmuinn>i cpeflHCBeKOBba B HCCJieflOBaHHe cjiyxoBoro aHajmsaTopa HOH6ojn,iimH BKjiafl BHCC A6y AJIH u6n Cnna (AsmieHHa). OH ormcaji napyjKHoe, cpeflnee,
BHyxpeHHee yxo H cjiyxoBOH nepa. BtmaroiuHHca ^earein. MC,UHUHHI>I SHOXH BospoacflCHHa OajinonHH onHcan uera. cnyxoBbix KOCTOHCK ox BiuiexeHHs MonoxoHKa B 6apa6aHHyio nepenomcy no coHneHCHHa naKOBanbHH co cxpeMeHCM. OH Taicnce ormcan HeKOTOpbie flpyrae flerajra cpeppero H BHyxpeHHero yxa, B HacxHOcra, saMerHB, HTO
<J)opMa H pasMep jia6HpHHxa nocjie poxmeHHa HC Menaioxca. ^anbHeraiiee pasBHrae
TeopHH cnyxa CBasano c H3o6pexeHHCM MHKpocKona B XVII BCKC, pasBHxneM anaxoMHH H 4>H3HKH. Ebuio c^ejiaHO MHoro nom,nx3K oGbacHHXb MexamoM cnyxa, HO see STH
TeopHH pyiinumcb, xaK KaK 6bicxpo pasBHBaiomaaca anaTOMHa H cj)H3HKa onpOBeprajm
BbiflBHHyxbie npeanonoJKeHHa. TCM HC MCHCC oana H3 nepsbK xeopHH, Koropaa flo naCToamero BPCMCHH HC yrpaimia cBoero snaneHHa, npeanoxceHa B XIX BCKC (1863 r).
HeMeuKHH ecxecxBOHcm>ixaxejn> H. Helmholtz BbmBHHyn xeopmo Ana 4)H3HOJioraHeCKoro oSocHOBaraia MysbncajibHbix (JteHOMCHOB, ocHOBaHHyio na saKOHax pesonaHca
K3K (})H3HHecKOH ocHOBbi BocnpHaiHa 3ByKOB BO BHyxpeHHCM yxe. Cyn. xeopHH B cjieAyromeM: GasHjiapnaa Me\i6paHa OT ocHosaHHa yjnrncH ao ee BepxynncH HMCCT pasnyio
iiinpHHy (paciimpaercfl npHMepno B 10 pas) H nonepeHHyro HCHepHeHHOcrt. Ee MOKHO
cpaBHHXb co cxpyHHbiM MyswKajiBHbiM HHcrpyMeHTOM, HanpHMep, ap<JK>H, rae BHCOKHC SByKH BOcnpOH3Bonax KopoxKHC H CHJibHO HaTaHyxbie cxpyHbi, a HHSKHC — HJIHHHbie H cjiaSo HaxaHyrbie. IlpH pacnpocxpaHeHHH 3ByKOBbix KOJieGaraoi onpeaeJieHHoft
nacxoTbi npoHcxonax pesonnpyiomHe coKOJieGaHHa oxaejibHbix ynacxKOB 6a3HJiapHOH
MeM6paHLI. BblCOKHC 3ByKH BOCnpHHHMaiOTCa B OCHOBHOM SaBHTKC yjIHTKH y OCHOBa-
HHa 6a3HJiapHOH MeM6paHbi, a HHSKHC — y Bepunmbi yjmTKH. TaKHM o6pa3OM, nepBHHHbrii anajms sayna nponcxonHT B yjmxKe. IlpH BCCH npocxoxe H npHBJieKaxenbHOCTH 3XOH xeopHH FejibMrojibuy ne yjjanocb c ee npMomj>K> ooiacHHTb see MexamoMti,
II. <t>M3Monormi cnyxoeoro aHajinaaxopa
71
KacaromHeca SByKOBoro npeoGpasosaHHa B ynHnce. IIpeanoJioaceHHe FejibMrojibaa o
cymecTBOBaHHH B oasmiapHOH MCNiGpane ox^ejibHbix BOJIOKOH, pesoHHpyioinHx noflo6HO crpynaM poajw npH BOSflCHCXBHH na HHX cxHMyjiOB onpenejieHHofi nacxoxbi,
BbBBano paa BospaaceHini. Bo-nepBbix, HH oajni MexaHHHecKHH pesonaxop He oSjianaex ocrpoxoH HacxpoHKH, xoxa 6w GJIHSKOH K HejiOBenecKOMy yxy. 3^ecb Bcxynaex B CHjry fleaxejibHOCXb ueHipanbHOH nepBHOH CHCXCMBI, HTO He yHHTHBaer xeopna TejibMronbija. Bo-BTOpbix, racrojiorHHecKHe Hccjie^oBaHHa noKasajm, HTO SasHJiapnaa MCM6pana — He naGop OTAejn.Hbrx H3OjmpOBaHHbix BOJIOKOH («cxpyH»), a uejibHoe o6pa3OBaHHC c nonepeHHOH HCHepHeHHOcxbio. B-TperbHX, TOHHaa nacTOTHaa HacrpoHKa
BOSMOKHa TOJIbKO HpH pa3HHHHOH CTeneHH HaT»»ceHHa «ClpyH» 6a3HJiapHOH MCM6pa-
Hbi, HXO HC cooTBexcTByeT aaHHHM npoBefleHHbix H3MepeHHH. B-HexBeprbix, XOHHO nacrpoeHHbiH pesonaTop Tpynno B036yflHTb, HO BbasaHHaa BH6pauHa coxpaHaexca aoBOJIBHO npo^oJMCHxejibHoe speivw nocne yracaHHa BosGyacflCHHa. ^^o Aejiaex HCBOSMOKHblM CBOHCTBCHHOe HeJIOB6Ky BOCnpHaTHC SByKOBbDC H pCHCBblX CHTHajIOB.
OflnaKO caM no ce6e (fiaicr npocxpaHCTBCHHOH noKaiiHsauHH ssyKOBbix nacTOT BflOJIb 6a3HJiapHOH MCM6paHH OHCEHflCH H nOflTBep^mCH SKCnepHMCHTaJIbHO.
O6tacHHTb 3x0 aBJieHHe noMoracx «rHflpoaHHaMHHecKaa xeopna», npeano>KeHHaa G. Bekesy. 3xa xeopna npeflcxaBJiena B 12-xn Bapnanxax, H paspaSoxKa HOBHX BapnanxoB npoapjiacaexcs, HO y BCCX B OCHOBC JIC»HX npHHiinnnajibHoe noo cymecxBOBaHHH B yjiHXKe, Hapaay c o6biHHHMH BOJinaMH cxcaxna,
raapoflHHaMHHecKOH BOJiHbi. CKOpocxb 3XOH BOJiHbi onpeflejieHa nacTOTOH, nocKOJibKy pacnpocTpaHCHHe ee npoHcxonnx B ^HcneprHpyiomeH cpe^e.
rH^poAHHaMHHecKHe BOJiHbi Moiyx rpynnHposaxbca M ycmiHBaxbca Ha onpefleneHHbix ynacxK3x (nanpHMep, K3K BOJIHU Ha nosepXHOcxH OKeana). BcKeuiH SKCnepHMeHTanbHo noKasan, HTO B GasnjiapHOH MeM6paHe BosHHKaioT nacTOTHo saBHCHMbie MaKCHMyMbi aMiuiHTyflbi MeflJieHHOH «6erymeH BOJiHbi». Bjiaroaapa
pacuiHpeHHio 6a3HJiapHOH MeinGpaHbi OT ocnoBaHHa K BepxyiiiKe, acecTKOCTt ee y
reJiHKOTpeMbi yMCHbiiiaeTCfl npHMepno B 100 pas. TaKOH rpaflHeHT
o6ecneHHBaex pa6oxy MeM6panbi noflo6no (})HJibxpy HHSKHX nacxox.
MCM6paHbi HeoflHHaKOBbi B pasHbix ynacxKax, HXO CBasano c oco6eHHocxaMH KpenMCM6paHbi K CTCHKaM yjiHTKH. 3TO onpeaejiaer xapaicrep H CTeneHb CMemepecHHHCK KJieroK ceHCOpnoro simxejHta. FIpHHUHn npocrpaHCTBeHHoro pacnacTOT B 6a3HJiapHOH MeMSpane oGycjioBJien H3MeHeHHCM ee MexaHHH6CKHX CBOHCTB B HpOflOJIbHOM HanpaBJICHHH: yMCHbUieHHeM ^CeCTKOCTH H BOSpaC-
xanHCM Maccbi. Bojibiuaa nacxb OCHOBHOH MCM6paHbi npejicxaBJieHa pajiHajibHbiMH
BOJIOKH3MH, oGpESyiOIUHMH KOMOaKXHWH OflHOpOaHblH CJIOH, SaKJHOHCHHBIH B FO-
MoreHHyio ocHOBHyio cyGcxaHUHio. CTpyicrypa OCHOBHOH MCM6paHbi cymecTBCHHo
OTJiHHaexca Ha ee npoxa»ceHHH OT ocHOBaHHa K sepxyuiKe yjiHTKH. Y ocnoBaHHa
yjIHTKH BOJIOKH3 6a3HJiapHOH MCIVlGpSHbl p3CIIOJIO»CeHbI GoJiee H3CXO. KpOMC XOFO,
B TO BpeMa KaK KocxHaa Kancyjia yjiHTKH yMCHbiuaercH no HanpasjieHHio K sepxyniKe, ocHOBHaa MeM6pana npH STOM pacuiHpaexca. TaKHM o6pasoM,
Me\i6paH3 ysKaa (0,16 MM), HO xoncxaa, a y
Teiua IV. YXO: CnVXOBOI/l AHAJ1M3ATOP
72
npHMepHO B 4 pasa iimpe (0,52 MM), HO SHannxejibHO xoHbine, TTO cos^aex onpe^eJICHHbJH rpaJJHCHX MCCCXKOCXH BOKpyr /UIHHHHK3 yjIHXKH.
HccjieflOBaHHa, npoBe^eHHwe B nocneflHHe roflbi, noKasbmaiox, HTO MexaHHHCCKHC npoueccbi, npoHCxojxauuie B yjiHXKe, ropasjjo cjKOKHee, HCM npe^craBJiaji ce6e
BeKeiiiH. HanpHMep, 3xa xeopna He o6i>acHaex BHCOKOH ycxoHHHBOCXH KOJie6axejn>HOH CHCxeMbi aaace npH SHaHHxenbHbix B HCH HSMCHeHHXx, c ee noMomwo HCBOS-
II. <t>M3Monornn cnyxoeoro aHannaaropa
73
HHXCHCHBHOCXb HO CpaBHCHHK) CO SflOpOBblM yXOM, COHCXaHHe C BCCXH6yjiapHbI-
MH paccxpOHCTBaMH H jjpyrHMH 3Kajio6aMH. OAHH HS HanGojiee ^ocxynHbix H
npocxbix cnoco6oB HCCJiejjoBaHHa cnyxa — axyMexpHH.
AKyMexpna — HccneflOBaHHe cjiyxa menoxHOH, pasroBopHOH peibio H xaMCpXOH3MH. ITpH HCCJieflOBaHHH CJiyxa UICnOXHOH H paSFOBOpHOH pCHbK) HCCJI6-
KaM paSHOH HaCXOXbl oSyCJIOBJICHO MCXaHHHeCKHMH CBOHCXBaMH 6a3HJMpHOH
jiyexca xonbKO BOS^yuiHaa npoBO^HMOcxb 3ByKa. OScJieaosaHHe nposoj^Hxca B
XHXOM noMemeHHH c fljiHHOH KOMHaxbi 6 H Gojiee MexpOB. IIpHcyxcxBHe jno^eH,
He ynacxByiomHX B HccjieflOBaHHH, HC xcenaxejibHo, nocKOJibKy HX fleficxBHa MOryx oxBjieKaxb BHHMaHHe nauHCHxa.
Bpan npoH3HOCHX cnoBa, cocxoainne H3 sayKOB HHSKHX XOHOB — OKHO, MaMa, ypoK, 22, 41, coflepacaiUHe 3ByKH [Y], [O], [M], [H], [P], [B]. B nopMe SXH
cjiOBa cjibiiiiHbi c 5-6-H M. 3axeM Hcnojibsyroxca cjiosa c BWCOKHMH SByKaMH —
saau, fl3ia, HHHC, usnna, coaepacsinne 3ByKH [3], [M], [HI], [H], [A], [5]. B nopMe
MCM6paHbi H nepeMemeniMMH cxon6a »CHIIKOCXH yiimofi HHM(J)bi.
3XH CJIOB3 CJIblUIHbl C 20 M.
KocTHoe SBVKonpOBeaeHHe. SsyKOBaa BOjma, ^eficxBya na noBepxnocxb nepena, BbisbiBaex KOJie6axenbHbie flBHaceHJW KOCXCH, KOCXHOFO naGnpHMxa H 3KHflKOCXCH BHyxpcHHero yxa — KocxHO-jia6HpHHXHbiH nyxb. KOCXHWC KOJie6aHHa
napy»cHoro cjiyxoBoro npoxoaa, CXCHOK 6apa6aHHOH nojiocxn nepe^aioxca na
uenb ciiyxoBbix KOCXOHCK — KOCxHO-6apa6aHHbiH nyxb. PasnHnaiox nnepi;HOHHbifi MexaHHSM SByKonpoBeflCHHa — Korfla nepeMemeniM raiacxHHKH cxpeMCHH
npOHCxoA»x no HHCPUHH BMCCXC c KOne6amwMH Bcero nepena, H KOMnpeccHOHHHH — Kor/ia BOSHHKarox KOJieSaHHa oxaenbHbix ynacxKOB nepena, xoxopwe
K Ae(J)opMaqHH nepena H caaBJiHsaHHio *H/IKOCXH yjinxKM. ^CHflKocxb
nepeMeinaexca 6jiaroAapa ajiacxHHHocxH OKOH. TaKHM o6pa3OM, Kocxnaa
ssyxa nossojiaex cyjjHXb HenocpeflcxseHHO o npouecce SByKOBocnpnaxHa, B xo BpeMa KaK Boaflyuinaa npoBOflHMOCXb CKJiaflbmaexca HS flsyx MC-
MeroflHKa npOBe/ieimn. HccjieayeMoe yxo naunenxa HanpsBJieno H3 spana.
Rpyroe yxo sarjiymaexca MacKHpyioiUHM myMOM. Cnoaa npOHsnocaxca cnanajia
menoxoM c paccxoaHHa 6 M. ECJIH o6cne/iyeMbiH He CJIMIUHX, xo span npH6jiH»caexca H CHoaa noaxopaex cjiOBa. ECJIH y yuiHOH paKOBHHbi o6cjieayeMbiH He CJIHUIHX, xo HcnoJibsyiox pasroBOpHyro, rpOMKyro penb HJIH KPHK.
M05KHO H o6taCHHXb MCX3HH3M peqenUHH SByKOB HaflnOpOrOBOH HHX6HCHBHOCXH.
TeopHH FeubMroJibua H EeiceiiiH flonojiaaex pun flpyrnx xeopHH. 3acjiy*HBaex BHHManHa xeopna A. A. YXXOMCKOFO, ocnoBSHHaa Ha <J>H3HOJiorHqecKOH JiaGmibHocxH HefipocxpyKxyp cnnpajibHoro oprana (Ka>Kflaa miexKa turn rpynna
KJICXOK pearnpyex na onpe^ejieHHyio nacxoxy 3ByKa). Corjiacno xeopnaM Ojiexiepa, VHBepa H flp., nsSHpaxejibHoe oxHoiueHne 6a3HJiapHOH raiacxHHKH K say-
X3HH3MOB - SByKOnpOBCfleHHa H SByKOBOCnpHaXHfl.
Meroflbi
c/iyxa
Bee BosMoacHbie cnoco6bi HccjieflosaHHa cnyxa MOHCHO pasflennxb na ase 6o;ibIUHC rpynnbi: cy6i>eKXHBHbie H oGteKXHBHbie. B nepaoH rpynne span oijeHHBaex
cy6-bCKXHBHbie omymemia nauHenxa H, KaK npasano, 3XH Mexoflbi Hcnojn.3yK)xca
npn saHHxepecoBanHocxH naujieHxa Bbiaanxb naxonomio cjryxa. Bo BxopoH rpynne
ocosnaHHoe yqacxne nauHenxa, paBHo KaK H sannxepecoBaHHOcxb naixHCHxa, pjia
OUCHKH cocxoaHna cjryxa 6onbinoro SHaHemw HC HMCIOX. 3xn Mexoflbi Hcnonbsyiox
/ma o6cneflOBaHHa aexen rpyflHoro H maflniero Bospacxa, wn B XJDKCJIOM o6meM
COCXOSHHH, npn npo<})eccHOHajibHOM ox6ope, B cjiynaax BpaneGHOH 3KcnepxH3bi.
CyEfeEKTUBHblE METOflbl MCCJlEflOBAHUfl
HaHHHarox HCCJie^oBaHHe cjiyxa c Bbias^eHHa »cajio6 na cHHacenHe cjryxa,
B yxe H anaMHesa pasBHxna sxoro CHMnxoMa — aaBnocxb, nocxeneHHOCXb,
Ecnu eosHUKaem HeodxoduMocmb uccnedoeamw cjiyxa y demeu,
noMHiane, nmo neped pe6eHKOM nyoKno cmaeumb nocwibnyio sadavy. Uoemopumb cnoeo, 3ncmemie Komopozo H&HOKOMO, mpydnee, a CMbicnoebie eonpocu eiauotaiom e cedn uccnedoeamie coo6pa3umejibHoanu, HMO He exodum e sadavy ucaiedoeww!
cxenenn xyroyxocxn:
I — menoxHaa peib 1,5-2 M ox yuiHOH paKOBHHbi, pssroBOpnaa peib ox 6 flo
3 MexpoB;
II — menoxHaa pe^b y yniHOH paKOBHHbi HJIH 0 M, pasroBopnaa peib ox 3 M
;io yniHOH paKOBHHbi;
III — uienoxHas penb 0 M, rpoMKaa penb y yuiHOH paKOBHHbi;
IV — nienoxnaa penb 0 M, KpHK y yuiHOH paKOBHHbi.
MCCJlEflOBAHME CHYXA KAMEPTOHAMM
Hccjie^yexca BosayuiHoe H KOCXHOC SByKonpOBeaeHHe, npn cpaBHCHHH KOxopbix MOXCHO BbiaBHXb, K3KOH oxfleji cjiyxoBoro aHanH3axopa cxpa^sex — 3ByKOnpOBOJXSmHH HJIH 3ByKOBOCnpHHHM3IOmHH. HcOOJIbSyiOXCa K3M6pXOHbI C 12 8,
Csi2, CiQ24, C2048-
Onbir PHHHC. 3Byn3mHH K3MepxoH C,28 flepacax xpeMa najibi(3MH 33 Hoacxy
y HapyacHoro cjiyxoBoro npoxoas Ha paccxoaHHH 1 -2 CM. ILnocKOCXb 6p3Hiu KaMepxona flon>KHa Haxo^nxbca B IIJIOCKOCXH cjiyxosoro npoxoaa. TaKHM o6pa3OM
sos^yuiHoe sByKonpoBeaeHHe. B HopMe 3ByK K3Mepxona BocnpHHH-
Teiwa IV. VXO: CjWXOBOI/l AHAJ1M3ATOP
74
Maexca B xeneHHe 60 cenyHfl. /Janee Hccne^yexca Kocxnaa npOBOflHMOCxb ssytca:
SBynamHH KaMepxon ycxaHaBJiHBaiox HOXCKOH Ha nosepxHocxb cocueBH^Horo oxpocxKa y Hapy»Horo cnyxoBoro npoxo^a — 3ByK KaMepxona cubiuien OKOJIO
30 ceKyna. B Hopiwe yxo BocnpHHHMaex 3ByK KaMepxona nepes Bosayx npHMepno
B 2 pasa flojibiue, HCM icpes Kocxb (nojiotfCHxejibHbift PHHHC). OxpHijaxejibHbiH
PHHHC — KOCXHOC BOcnpHaxne ssyna npeo6naflaex najs. Bos^yiuHbiM, HXO CBHACxejibcxByex o HapymeHHH SByKonpoBeflCHHa (KOH^yKXHBHaa xyroyxocxb). MaJibiH nojiOKHxejibHbiH PHHHC — yKOpOHCHHC BOcnpHHXHfl 3ByKa H Hepes Bosflyx,
H qepea Kocxb npH HX nopManbHOM cooxHoiueHHH — CBnaerejibcxByex o nopa-
cnyxoBoro aHann3axopa
K annapaxHWM cy6teKXHBHbiM MexoaaM nccjieflOBaHHa oxHocnxca
MexpHa, Koxopaa nosBOJiaex 6onee XOHKO oiieHHXb noporn cjiyxa npn BO3/iyiiJHOH
H KOCXHOH npoBOflHMOcxH Ha GoJibiuoM ananaaoHe nacxox (xonajibHaH ay/jHOMexpna), nosBOJiaex Bbiaanxb (JjenoMCH ycKOpeHHoro HapacxaHHa rpoMKocxn (naanoporoBaa xonanbHaa ayAHOMexpna), xapaKxepnbiH ^na KoxjieapnoH naxojiornH,
paccxpoHCXBa noHHMaHHa penn — peneBaa ayaHOMexpna.
CjiyxoBOH nacnopr HopmajibHO CJibiuiauiero
HOH nOABHXCHOCXH CXpeMCHH FpOMKOCXb BOCHpHflXHa 3ByKa npH H3M6HeHHH £36-
jieHHa Menaexca — nojio>KHxejibHHH >Kejuie. IIpH HenojiBHHCHOcxH cxpeMeHH
rpoMKOCXb BOcnpHaxaa ssyxa HC Menaexca — oxpHtjaxejibHbiH )Kejuie.
Onbir HHHI a — onpeacjieHHe cxeneHH noaBHKHOCXH cJiyxosbix KOCxo^eK.
SBynamHH KaMepxon C12g ycxaHaBJiHBaiox na cocueBimHbiH oxpocxoK H naunenx
saKpwBaex nanbucM HapyacHbiH cnyxosoH npoxo^. IlpH coxpaneHHH noflBH)KHOCXH CJiyXOBblX KOCXOH6K IpOMKOCXb 3ByKa H BpCMa 3ByHaHHH yBCJIHHHBaiOXCH
(nojio)KHxejibHbiH onbix BnHra). IlpH oxcyxcxBHH xaKOBOH (HapymeHHC ssyKO3x0 pasjinnne nocxeneHHO nciesaex snjioxb flo nojiHoro BbipasHHCJIblUIHMOCXH npH OXKpblXOM H 33KpbIXOM yXC.
Onbir OeaepHHe — cpaBHeHHe KocxHO-xpameBOH npOBo^HiwocxH c KOCXHOH. 3BynamHH KaMepxoH nepnoflHHecKH npHKJiaabiBaiox K KosejiKy H cocueBHflHOMy oxpocxKy. B nopivie /lOJibine BocnpHHHMaexca ssyK c KoseJiKa. Ilpn HapySByKonpOBeACHHa — c cocueBHanoro oxpocxKa.
KopoxKO B MC/IHIIHHCKOH flOKyMCHxauHH Mcxoflbi HccjicflOBaHHa cjiyxa yxaB xa6jiHue cnyxoBoro nacnopxa 6o;ibHoro.
6M
20 M
30 C6K
60 C6K
+
—>
HopMa
+
+
K>C
Jleeoe yxo
TecTbi
OpaBoe yxo
5KCHHH SByKOBOCnpHaXHa.
Onbir Be6epa — onpeflenenHe jiaxepannsauHH ssyica. SBynamHH KaMepxoH
Ci28 ycxanaB^HBaKix na xeMCHHyio o6nacxb naiiHenxy H cnpaniHBaiox: «r^e
cjibimcH 3ByK — B cepeflHHe ronoBbi HJIH B KaKOM-xo yxe CJIHUIHO jiyHiue?» B
HopMe 3ByK cjTbiuieH B cepe^HHe FOJIOBW HJIH o^HnaKOBO B o6onx yiiiax. B 6onbHOM yxe cjibiuiHO Jiynuie — 3H3HHX HMCCXCH HapyineHHC SByKonpOBeaeHHa. B
3flopOBOM yxe cubiiiiHO nynuie — napyuieHHe 3ByKOBOcnpH»XHa.
OnbiT UlBaOaxa — cpaBHCHHe KOCXHOH npOBOflHMOCXH ssyxa y naqHenxa H
spana (span flOJi»eH HMexb HopManbHbiH onyx). SBynaiyHH KaivrepTOH C^g ycxanaBJiHBaiox na coctteBHjjHyio o6nacxb naiinenxa H, Kor^a OH nepecxaex cjibiuiaxb,
nepenocax na cocueBH^Hyio o6;iacxb apaia. Kocxnaa npOBOflHMOcxb
yKoponena — HapyiiieHHe SByKOBOcnpnaxHa. Kocxnaa npOBOflHMOcxb
yzyiHHHeHa — HapymeHHC SByKonpOBe^eHHa. KociHaa npoBOflHMOcxb
H apana oaHHaKosa — nopivia.
OHBIT ^CejiJie — onpe^ejieHHe noflBHacnocxH cxpeMCHH. BsyHainHH KaMepXOH CHS ycxanaBJiHBaiox na cocueBH^HbiH oxpocxoK. O^HOBpeMeHHO 6aiuioHOM
^OJIH^epa HSMenaiox ^aBJieHHe B napy>KHOM cjiyxosoM npoxoae. IlpH coxpaneH-
75
Cy6i>eKXHBHsiH uiyin
IllenoTHaa pens
PasroBopHaa pent
C128 KocxHoe SByKonpOBCflCHHe
C128 BOS^yiiiHoe sByKonpoBeaeHHe
R
W
Sch
)K
B
F
6M
20 M
30 C6K
60 C6K
+
<—
Hopina
+
+
K>C
ayAHOMexpHH 4>nKCHpyioxca B BHfle rpa(J)HKa — ayAHorpaMMbi, Ha
Koxopofi oxMCHaioxca noporn CJIHUIHMOCXH B p,E nnst Bos^ymnoro H KOCXHOFO
nexbipe xnna ayflHOMexpHHCCKHX KpHBbix (pHC. 16): I ropHsonXHH rpa(J)HKa xapaKxepeH jm% KoimyKXHBHOH xyroyxocxn, OOJIBSHH
MeHbepa na panned cxa^nn; II HHCxoaamHH xnn KPHBOH xapaKxepen aJia CMemaHOH, ceHCOHCBpajibHOH xyroyxocxn; III XHH — Bocxo^amaa KpHBaa, xapaKxepnaa /uia oxocioieposa; IV XHH — o6pwBHcxbiH HHCXOAamHH rpa(j)HK, xapaKxepHbiH fljia ceHCOHCBpaJibHOH xyroyxocxH.
N
db
0
;==•
20
40
60
80
100
kHz 0,25
^PVBBi*
^m :—
•^^S
— *, •^
0,75 1,5
•*•
3
I-*1
6
10
76
TeMa IV. YXO: CJiyXOBOft AHAJ1H3ATOP
77
. 3>v\3v\or\orvm cnyxcmoro aHannaaropa
250 500 IK
db
2K
4K 8K
V
0.
20
^*- •
^,
•_
"*
* *
—
40-
—
""^=
•"-^
muff
«*^,
/C/)- ^^
100
0/1.
oU
i finL-H?
6
10
250 500 IK 2K 4K 8K
n
0,125 0,25
0
20
40
60
80
inn
3
0,75 1.5
Puc. 16. Tmihi ayflHOMexpHHecKHX KPHBMX:
a — I THH ayflHOMerpHiecKoii KPHBOH cooTBeTCTByer HopMajibHOMy cjiyxy;
6 — I THH ayflHOMCTpHHecKOH KPHBOH, KOHflyKTHBHaa TyroyxocTb;
e — II THH ayflHOMeTpHiecKOH KpHBOH, cencoHeBpajibHaa TyroyxocTb;
^ — III THn ayflHOMeTpHiecKOH KPHBOH, OTOcmiepos;
d — IV inn ayflHOMeTpHiecKOH KPHBOH, ceHCOHespajibHaa TyroyxocTb
O6-beKTMBHbie MGTOflbi MccjieflOBaHMfl cnyxa
"•v^_
*v ^
BESyCJIOBHblE PE4>J1EKCbl
^^ "**.
"v
1 . AypHKyjionajibneSpanbHbiH pe4>JieKC — MOpranHe noa BimaHHeM HCO>KHpasaaBiuerocfl sayica. Moacer conpOBoamatbCfl o6mHM flBHrarejibHbiM
, noBopoxoM roJIOBbl B cxopOHy ssyica, saMHpaHHCM, uiHpOKHM pacrjias.
2. BerexaTHBHbie peaKUHH:
— HSMCHCHHe cepflue6H6Hiw B OTBCT na
**
db
peaKUHH — HSMCHCHHe HIMPHHU
N
0 - _.
"""•
20
40 / ,/ ———"
60
80
100
0.25 0.75 1,5
kHz
1
""
".
-
'
^ •
«.
MW
=*• *^ **•
CTH B OTBCT H'd 3ByK.
-R?T
^
•*•
^-<
3
6
— pe^JieicropHoe noBbimemie noxjiHBO-
^. mm
""^
B OTBCT na
10
BesycjioBHbie pe^jiexcw nosBOJMiox cyjenaxb saKjiKj^eHHe o HanHHHH cnyxa
Boo6me, 6es onpeaeneHHa xyroyxocxH.
CjiyxoBtie BbOBaHHbie noTCimnajibi — perHcrpauHH 6H03JieKxpHnecKHX
ro^oBHoro Mosra c noMOiajbio KOMnbioxepHofl nporpaMMbi,
npoBOflHXb HX HaKoiuieHHe, cyMMauHro H ycpeAHCHHe.
HMneaaHcoiweTpHH — nosBOJwex onpeaenHTt
yxe, xonyc H crenenb OOABHWHOCXH 6apa6aHHoft nepenoHKH, <})yHKUHOcocxoaHHe uenH cjiyxosbix KOCXOHCK, <j)yHKUHio cnyxoBOH Tpy6bi, nopor
pe<J)neKca.
78
Tewa IV. YXO: CJ1YXOBOI/I AHAHM3ATOP
Bonpocbi MToroBoro KOHrponn 3H3HMM no rewe IV
1. KaKne aHaroMMHecKne o6pa3OBaHna OTHOCHTCH K nepncpepi<iHeCKOwy OTfleny cnyxoBoro aHanMsaropa?
2. nepeHMcnme anaTOMMMecKHe o6pa30B3HMfi, BXOflflinne B cucTewy
cpeflHero yxa.
3. riepeHMcnMTe creHKM 6apa6aHHOM nonocTM.
4. HasoBMre onosHaBarenbHbie nyHKTbi 6apa6aHHOM nepenoHKM.
5. B new saitnioHaeTCfl KnuHnsecKoe SHaneHne cooSmeHun cpeflHero
yxa c HocornoTKOM?
6. KaKHe runbi crpoeHmi cocueBHflHoro orpocTKa Bbi snaere?
7. 3a CM6T K3KMX MexaHMSMOB o6ecneMHBaeTcn ycM/ieHne asyxa npM
nepeflane ero us BHewHeii cpeflbi K peqenropHbiM K^eTKaM KopTMeeoro
oprana?
8. rlepeHMCJlHTe MssecTHbie saivi cy6teKTMBHbie M o6beKTMBHbie weTOflbi nccneflOBaHMfl cnyxa.
9. FlepeMHcnMTe KaMeproHa/ibMbie npo6bi nccneflosaHMfl cnyxa.
10. KaKne rnnbi ryroyxocTM Bbi aHaeie?
11. B HBM saKntoMaercfl oco6eHHOcib KpoBOCHaGweHMH BHyrpeHHero
yxa? KaKMe 3a6oneBaHnn Moryr npMBecTM K passMTmo ceHCOHeepajibHoii
jyroyxocTM?
eMa. V
YXO: BECTMEyriflPHblM
AHAJ1M3ATOP
BpeMfl 3aHHTMH — 180 MMHyT.
LJenb saHnTMfi: na OCHOBB aHaTOMMMecKoro crpoeHMn BHyrpeHHero yxa, saKOHOB dpn3nonornn nonyKpy>KHbix KananoB HayHMTbcn MccneflOBatb dpyHKMHK) secru-
1. HsyMMTb TMHbl B6CTM6ynS1pHblX peaKL|MM.
2. HayMMTbCfl oqeHMBaTb HkicrarM.
3. HayMMTbCH npOBOflmb n oqeHMBaib CTaro-KMHeKOOpflMHaqMOHHbie, BpamarenbHbie npo6bi B
BecTn6ynflpHoro aHanMsaiopa.
ripu nodzomoBKe K 3anamuio noemopumt,
c npeduiecmeyiomux xypcoe:
aHaroMMfl — crpoemie BHyrpeHHero
flonosiHumenbHO dnn neduampu^ecKoeo <pai<yfibmema:
12. KaKOBbi aHaroMMMecKMe oco6eHHoc™ 6apa6anHoii nepenoHKH y
flereti paHHero M M/iafluiero sospacra?
13. KaKMM o6pasoM BOSMTOKHO Mccneflosarb cnyx y flereii nepeoro rofla >KM3HM?
yxa;
— HeeponorMH — CMHflpowbi paccrpOMCTB
. OcBeiMTenbHbie npn6opbi: HCTOHHMK
csera, no6Hbiii pecpneicrop, OTOCKOO, napMHrocKon, BOnoKOHHan oniMKa.
Ha6op MHCTpyweHTOB. HocoBbie sepKana, liinarenn,
yniHbie BOpoHKM, ropiaHHbie n HocornoTOHHbie sepKana,
i HasMBHbie, nnHL(eTbi yiiiHbie, nHHqerbi Hocosbte.
Pa6onee MCCTO. HHcrpyMeHTanbHbiM cronnK, HanaMna, cnnproBKa, flsa ciyna.
Mecro npoBefleHMH aaHnmn. YMe6Ha?i KOMHaia,
OTfleneHkie OTOpnHonapnHronornn.
PeKOMeHflyewan nnyeparypa:
1 . Co/idamoe M. B. JleKUMM no OTOpnHonapnHronoFMH. — M.: MeflMMUHa, 1990.
2. Mcxaxu K). B., Kanbiumeun fl. M. flercKan oropnHonapMHronornn. — flyuuaH6e: Maopwdp, 1985.
80
TeMa V. YXO: BECTHEyjlflPHblM AHAT1H3ATOP
3. RMumpueHKO M. Arnac KjiHHUMecKort aHaroMnn (oxopMHOJiapHHro/iornfl). —
MocKBa,1998.
4. BnaaoeemeHCKan H. C. OTOHeeponorMHecKne CMMnroMbi M
M.: MeflnunHa,1990.
I. AHATOMMfl riEPMOEPMHECKOrO PEUEHTOPA
BECTMBYJlflPHOrO AHAJ1M3ATOPA
! KnexKH nepHc^epHHecKoro peuerrropa BecxH6yjiapH9ro ananHaaxopa pacnonaraioxca B npe/WBepHH H nonyKpyacHbix Kanajiax BHyxpeHHero yxa (pnc. 17).
— qenxpajibHaa nacxt JiaSnpHHxa — cnepejiH coo6iuaexca c
— c nonyKpyacHbiMH KananaMH. Hapy>KHaa cxeHKa npe^BepHa
— 3x0 BHyxpeHHaa cxeHKa 6apa6aHHOH nojiocxn. B sxoii CXCHKC pacnonaraexca OBajibHoe OKHO, B KoxopOM Kpennxca noflHO>KHaa nuacxHHKa cxpeMeHH. BnyxpeHHaa cxeHKa npeansepHa cooTBexcxByex any BHyxpeHHero cnyxoBoro
npoxofla[Pejierixopbi BecxH6yjiapnoro anajinsaxopa naxoaaxca B asyx MeuioHKax
— c<J)epHHecKOM (sacculus) H sjuiHnxHHecKOM (utriculus). MCUIOHKH
Mc>Kay co6oH coe^HHeHbi KananoM — ductus utriculo-saccularis, KOxopbifi npoflO^Kaexca B 3HflOJiHM<J)axHHecKHH npoxoK (oGpasya BOflonpOBOfl
H saKaHHHBaexca pacuinpeHHeM flynjiHKaxypbi xBepaoii MOSFOBOH i
KH
ITOBepXHOCXH nHpaMHJlbl
3HflOHHM(J)aXHHeCKHM MCUIKOM (j)HC. 18).
Ha BHyxpeHHeH noBepxnocxH MCUIOHKOB npeAasepna HMeioxca cxaxHHecKHe
FAC H pacnonaraioxca peuenTopbi_BecxH6yjiapHoro ananHsaxopa —
annapax. OxojiHXOBbie
MCUIOHKOB pacnonoMceHH BO B3aHMHO nepneHflHKynapHbix
3
ruiocKOcxax: B ctJjepHiecKOM MeriiOHKe — carHxxanbHO, B SJUIHIIXHH6CKOM MeniOHKC
peqenTQpa BecTn6ynapHoro aHann3axopa
I.
JIHXOB, Koxopoe Bbisbisaex CMemcHne UHJIHH
ceHcopHbix KnexoK. KaHyiaa Kjiexica cnocoSna
oxBenaxb BO36y>K/ieHHeM na CMCIUCHHC cxcpeOUHUHH B CTOpOHy KHHOUHJIHH XOpMOJKC-
HHBM npn ABHaceHHH cxepeoqHJiHH B npoxHBonojio»oiyio cxopony.
B Ka^yioH BHCOHHOH KOCXH aMnynapHbie peuenxopbi pacnonoxceHbi B Kpncxax
aivmyji xpex nonyKpy)KHbix KananoB, KOXOpue pacnono)KeHbi B xpex ssaHMHO nepnenPUC. 18. 3HflOJlHM(})aTHHeCKHH
^HKyjiapHbix nnocKOCxax (pnc. 19). BwaeiipoxoK:
jiarox OAHH ropHSOHxajibHbiH Kanaji (ero >KC
1 — c4>epmecKHH MemoMeK,
Hasbmarox jiaxepanbHWM, Hapy»CHbiM) H ^Ba
2
3JlJlHnTHIieCKHH MeiUOHCK,
sepxHKanbHbix Kanana — (J)pOHxajibHbiH H
3
3HflOJlHM(J)aTHHeCKHH npOTOK,
carHxxanbHWH. Kanajiw o6onx jiaGnpHnxoB,
4
3HHOJTHM(})aTHHeCKHH MCUIOK
B OflHOH HJIOCKOCXH, cocxaBJiaiox
ojjHy <})yHKUHOHajibHyio napy. FLiocKocxb ropHSOHxajibHbix nonyKpy5KHbix Kana
JIOB pacnojiaraexca noR yraoM 30° K ropHsonxajiH. BepxHHH Kanaji OAHOH cxopo
HH H HH>KHHH KaHaji jipyroH cxopOHbi npaKXHMecKH napajiJieiibHbi H Jieacax no
yrjioM 45° K 4>poHxajibHofi IIJIOCKOCXH. TaKHM o6pa30M, xpn napw KanauoB o6ec
neHHBarox peaKUHK) na yrnoBbie ycKOpCHHa B nioSoH HJIOCKOCTH.
B aMnyjiapHbix peuenxopax xpex no;iyKpy>KHbix KananoB co^epafHxca npn
MepHO 16-17 xwcan KJiexoK. KonnanoK Kynynw, naBHcaa naa peuenxopoM, ^oc
xnraex npoxHBonojioxcHOH cxoponbi CXBHKH aMnyjibi. CySKynynapnoe npocxpan
CXBO aMnyjibi sanojiHCHO BasKHM ceKpexoM onopnbix KJICXOK, npoHHsano cxepeo
UHJiHaMH, Koxopbie Bflaioxca B acejiaxHHOo6pa3Hoe BeiuecxBO caMoft Kynyjibi
Kaacaaa cxepeoijHJiHa naxoflHxca B ox^eJibHOM y3KOM KaHajie. Ilpn
BOJiocKa B Kanane npoHCxoanx o6pa3OBaHHe sjieKxpHHecKoro HMnyjibca.
Kocmnuu FfepenoHuanibiu
jiaQupunm Jia6upumn \
OmpocniKii
FOpH3OHXajlb-
HO. IlaTHa (MaKyjibi) c^epHiecKoro
H SJUIHFIXHHeCKOrO MCEIOHKOB CO-
aep*ax COOXBCXCXBCHHO 7500 H
9000 KJICXOK HeHpOSHHTCJIHa.
Puc. 17. VUIHOH jia6HpHHx:
Ha/i muiwaMH ceHcopHbrx KnexoK
MaKyn HaBHcaex MCMGpana cxaxoKO-
1 — yjiHTKa, 2 — npeflflBepHe jia6HpHHTa
BHyrpeHHero yxa, 3 — OBanbHoe OKHO,
4 - .pyraoe OKHO, 5 - nepeflHHH (eepXHHft,
(ppoHTanbHbiH) nojiyKpyjKHbiH Kanai, 6 — sajUHHH
(HHJKHHH, carHirajibHbift) nonyKPy>KHbiH Kanaji,
7 — ropHSOHTajibHbiH (jiaTepajibHbiii, SOKOBOH)
HHH. Ee BCmCCXBO npOHH3aHO BOJIOKH3MH, B nCXJiaX KOXOpbDC paCHOHO^Ce^ ^ClWmi KaJlbUHXa (oXOJIHXbl).
_
B ^PCSyJIbXaxe
^CHCXBHa npaMOJIHHeHHbK yCKOpCHHH HUH CHJIbI xa»CCCTH
npOHCXOZlHT
CMemCHHC
OXO-
81
KJiemoK
AMtiynstmopH biu
zneoeutoK
'
mopubiu Hepe
VmpuKynnmopHbiu Hepe
3HdomiM(pamu
.-.
Umomtnibi
Baiocnoebie
Kjiermcu
Onopnbie
KJieniKti
Puc. 19. PeaenxopHHH annapax BecxH6yjwpHoro anajiHsaxopa
82
Tewia V. YXO: BECTMByjlflPHbll/l AHAJ1H3ATOP
II. a>M3MOJlOrMfl BECTMEYJlflPHOrO AHAJ1M3ATOPA.
METOflbl MCCJIEflOBAHMfl BECTMBYJiaPHblX PEAKUMM
pa3flpa>KHxejiaMii jecrHGyjiapHoro anajinsaxopa aBJiaioxca:
ycicopeHHe, CHJIE xa5KecxH_(,aJia OTOJiHTOBoro annapaxa) ^
BWC' ycKopeHHH (AIM nojiyKpyacHBix KanajioB). BMCCTC c TCM, BecxnGyjiapHbie peclKUHH MOPyX BOSHHKaxb npH BOSflCHCTBHH Ha BHyXpCHHCe yXO <j>H3HHeCKHX (})aK-
xopoB (HSMCHCHHe xeMnepaxypbi, flaBJieHHa); ^DSACHCTEHH XHMHHCCKHX BemecxB — ynoxpe6jieHHH HeKoxopbix jieKapcxBeHHbJX npenapaxos;
CKoro xoKa; ncHxb-3MOJlHOHajibHOM BOSACHCXBHH H ^P- BceBO3MO)KHbie
opraHH3Ma B OXBBX Ha pa3/ipa«eHHe BecxnGynapHoro aHajiHsaxopa pasflejiaiox na
xpH XHna peaKUHM:1) BecxnSyjio-ceHcopHbie (omymcHHe rojiOBOKpy>KeHHa, XOIHHOXH);
2) BecxH6yjio-coMaxHHecKHe (ruasoflBHraxejibHbie peaKUHH, HSMCHeHHe noxoflKH, KoopflHnauHH ^BHJKCHHH, HSMCHCHHe xoHyca Mtiiiiq);
3) BecxH6yno-BerexaxHBHbie (HSMCHCHHe apxepHaubnoro aaBJieHHa, nacxoxw cepflCHHbix coicpameHHH, BJia»(HocxH KOHCHOFO noKpOBa,
pBOxa).
BecTHSyjio-cencopHwe pcaKuim cy6ijeKXHBHbi. Hx HccneaoBamie
ca B BbWBueHHH y 6onbHoro »ano6, yKaabreaioiuHX na naxojiomK) BecTH6ynapHoro
anajiHaaxopa. Jlfw. naxonoraH nepH(J>epHHecKoro ox^ejia BecxnGynxpHoro
xopa xapaKxepno HajiHMHe npncxynoB BpamaxenbHoro ro^OBOKpyaceHHa
xapaKxep rojioBOKpy>KeHna), ycunHsaiomerocH npn nepeMene nono»ceHHa TOJIOBH.
Jlpyme BHZJW ronoBOKpyHceHHH (ocasaxejibHbie — oiyymeHHC npoBajmBaHna, BSJICxa, nepeMemcHHa npe^MexoB H x. a. — ne aBJiaioxca CHCXCMHUMH) BosHHKajox npH
naxojiomH MosxceHKa, npoBO/wmnx rryxen H uenxpoB BecxnGynapHoro anajiHsaxopa.
TouiHOxa npH nopajKCHHH nepH(J)epHHecKoro oxflena BecxH6ynapHoro ananHsaxopa
HC CBaaana c npweMOM nnmH, BOSHHKaex Ha <J)OHe rojiOBOKpy^ceHKa HJIH aBJiaexca
ero npeflsecxHHKOM. IlpHcxyn rojioBOKpy5KeHHH MTOKCX conpoBO)Kflaxbcx cJiyxoBbiMH paccxpoBcxBaMH (myM B yxe, cnroKCHHe cjiyxa), HXO CBasano c Mop4)o-(J)yHKi(HoHajibHbiM eaHHCXBOM BHyxpeHHero yxa, Gjinsocxbio pacnojioaceHHa BOJIOKOH BCCXHSyjMpnoro H yjiHXKOBoro KOpeuiKOB B cnyxoBOM Hepse.
BecTHgyjio-coiviaTHHecKHe peaKUHH oGteKXHBHbi. K HHM oxnocaxca: cnoHxanHblH HJIH 3KCnepHM6HXajIbHO BblSBaHHblft HHCTaFM, H3MCHeHHe XOHyca CKCJieXHOH
MycKyjiaxypu npaBOH H JICBOH nojioBHHbi xejia, HapymcHHe Koop^HHauHH
HHH, HapymcHHe noxoaKH. HccjieaoBaxb MOHCHO cnoHxaHHbie BecxH6yjwpHbie
UHH, a xaK»e BbBBaHHbie npH HOMOUIH aACKBaxHbix pa3flpa)KHxeJieH (spamaxenbHbie
npo6u) HJIH HeaaeKBaxHbix pasApaaanejieH (npeccopnaa, KanopHHCCKaa, ranbBaHHnpoSw). Opn HCCJieflOBaHHH BecxnGyjiapHoro aHajinsaxopa afleKBaxHbiMH
(ycKopeHHHMH) B03A6HCXBHK) noABepraexca Bee xejio nauHenxa. B
3XOM cjiynae npnxoflHxca aHajiHSHposaxb pearaiHH, BosHHicuiHe npn ynacxHH H npaBoro, H jiesoro yuiHbix jiaGnpHnxoB. IlpeHMyinecxBO npo6 c HcnojibSOBaHHCM
BecTn6ynapHoro aHannaaxopa. Mexoflbi
83
KBaxHbix pa3Apa>KHxejieH aaionoHaexcH B XOM, HXO npn HX noMomn BOSMO^CHO HCCJICaosaxb HSOJinposaHHO yiiiHOH JiaGnpHHx O^HOH nojioBHHbi rojioBbi.
K Mexo/iaM HCCJieAOBaHHH BecxH6yjio-coMaxHHecKHX peaKUHH oxHocaxca:
1 ) HCCJieaosaHHe HHcxarMa;
2) KOOpAHHauHOHHwe iipoSw;
3) cxaxoKHHexHHCCKHe npo6w;
4) BpamaxejibHbie npo6w;
5) KajiopHHCCKHe npo6w;
6) rajibBaHHHecKaa npo6a.
HncTarivi — HenponsBOJibHwe PHXMHHHHC ABH»CHHa raasHbix »6jioK.
jiaBHpHHXHoro HHcxarMa xapaKxepno HanHine aayx (J)a3 — 6bicxporo H
ro KOMHOHenxa. HanpaBJieHHe HHcxarMa onpeaenaiox no 6bicxpoMy KOMnoneHxy,
nocKOJibKy OH jiymie saMexen. HacxarM MTOKCX Ha6niOflaxbca npn nopaaceHHH
pasHbix SBCHbeB BecxH6yjiapHoro anajinsaxopa, H B saBHCHMOcxn ox ypOBHfl nopaaceHHa BbmeJiarox jiaSnpHHXHbiH H uempajibHWH HHCxann. /Jjia BbiaBJieHHa cnonxaHHoro HHcxarMa npewiaraiox 6oJibHOMy 4)HKCHposaxb ssrjiaa na nanbue Bpana
Ha paccxoaHHH 50 CM ox ruas 6oJibHoro na JIHHHH tiyxb Bbiiiie ypOBHa raas. 3axeM
npoH3BOAax aBH^ceHHa najibueM BBepx, BHHS, BueBO, Enpaao H cjie^ax sa flBHHceHHaMH raas naunenxa. HccjieAoaaxb HHCxara ne nyacHO B KpafiHHX oxBe^eHHax na
rpaHHue 3pHxejibHoro nona, nocKOJibKy no^eprnBaHHe raasa MOMCCX
npH npesMepHOM HanpaxceHHH rjiaso^BHraxejitHbix MHUJU.
cnoHTaHHoro HncrarMa
1 . Y 3flopoBbix JIHU:
- 4>HKCaUHOHHbIH - BO3HHK3eX
H3 OHpe-
npe^Mexe, npn Bsrjiaae B KpaHHCM
— ycxaHOBOHHbiH — BO3HHKaex B KpaftHHX oxBCflCHHax rjiasa, 3axyxaex B
XCHCHHe HeCKOJIbKHX CCKyHfl;
- OnXOKHHCXH^eCKHH - BOSHHKaet npH CJieHCCHHH 3a 6bICXpO
ca npeflMexaMH (»cejie3HOflopo»cHbiH).
2. naxononwecKHH HHCxarM:
- MaaXHHKOo6pa3HbIH - (MblUieHHblH) BpO»meHHbIH HJIH
jiroflCH, HC HMeex Gbicxporo H MefljienHoro KOMHOHCHXCB;
— HHCxarM yrjieKonoB — BOSHHKaex npH juiHTejibHOH pa6oxe B XCMHOXC;
— MOHOKynapHbiH — BOSHHKacx npH nopaxceHHH Mbiuie^Horo annapaxa
Horo rjiasa, rjiasoflBHraxejibnux HepsoB HJIH npOBOflauiHX nyxeii
anajiHsaxopa B CXBOJIC Mosra;
— pexpaKUHOHHbiH (B carnxxajibHOH IIJIOCKOCXH) — nyjibcnpyroiuee
HHC rna3 npH nopajKCHHH cpe^Hero Mosra;
— KOHBeprHpyiomHH — flBH^eHHa rjias HanpaBJicHbi HaBcxpeny apyr apyry,
BOSHHKaex npH nopaaceHHH o6:iacxH nexBepoxojiMHa;
84
Teiwa V. YXO: BECTHEyjlflPHbll/l AHAJ1H3ATOP
— HHcxarM nojiOMceHna (nosHUHOHHbiH HHCxarM) — noaBJisexca B onpeaeJICHHOM nojiOHceHHH rojiOBbi H xyjiOBHma H Menaex ceoe HanpaaneHHe H HHXCHCHBHOcxb npn nepeMene HX nojioaceHHa.
3. BbBBaHHbifi 3KcnepHMeHxajibHbiH HHcxarM noApasAejiaiox Ha: nocxBpamaxeJlbHblM, IlpeCCOpHblH, KanOpHHCCKHH, rajIbBaHHHCCKHH, OnXOKHHCXHHeCKHH, HO-
II. <Dn3nonorMa Becxn6y/iapHoro aHanuaaxopa. Meroflbi nccneflOBaHMa...
85
acena oxpimaxejibHo, a porosHua nono)KHxejibHO, B CBSSH c HBM BO3HHKaex KopneopexHHanbHbiH noxeHHHair noKoa, Koxopbiii Menaexca npH Ka-xaou flBHaceHHH raaa.
He3HaHHxejibHoe oxKJioneHHe aneKxpHnecKOH OCH raasa BO Bpeww nncxarMa Bbisbisaex HSMeneHHe Kopneo-pexMHajibHOro noxenuHajia, nanpaBJieHHe H Bonbxa)K KOxoporo xapaKxepHsyiox onpeaeneHHoe ABH^ceHHe raasHoro
3HUHOHHWH.
IIpH BbiasjieHHH HHCxarMa ero oueHHsaiox no cjieayiomHM napaMexpaM:
— no njiocKOCXH (ropHSOHxajibHbiH, BepxHKajibHbiH, AHaroHajibHbiH, poxaXOpHblH, MHTOKeCXBCHHblH);
— no HanpaBJieHHio (npM B3raaAe BnpaBO, BJICBO, Bsepx, BHHS);
— no CHUB (I cxeneHH — BOSHHKaex npn Bsrjia^e B cxopony 6bicxporo KOMnoneHxa, II cxeneHH — oxMenaexca npn Bsraaae B cxopony 6bicxporo KOMHOHCHxa H npaMO, III cxeneHH — BOSHHicaex npn BsraaAe B cxopony 6bicxporo
KOMnoHCHxa, npaMO H MeAJieHHoro KOMnoneHxa);
— no aMiuiHxyAe (MCJIKO-, cpe^ne- H KpynHOpasMafflHCXbifi);
— no Hacxore (KJIOHHHCCKHH — HopManbHoe HepeflOBaHHe Gbicxpofi H MCA4>a3 HHCxaraa, KJiOHOxoHHiecKHH — yzuiHHeHHe MeaneHHOH 4>a3ti
— no /umxejibHocxH (ceKyHflw, Mecaubi,
XapaKxepncTHKy nncxarMa sanncbiBaiox B BHjje (JjopMynbi: SNyHL-1 (COOHxaHHbift HHcxarM, roprooHxajibHbiH, BJICBO, nepsoH cxenenn), aanee yicaabiBaiox
ocxanbHbie napaMexpu. CnoHxaHHbiH Jia6HpHHXHHH HHcxarM sBjiaexca ropHsonxajibHO-poxaxopHWM, HMeex HCXKO Bbipa5KCHHbie 6bicxpbiH H MeaJieHHbiH KOMHOHCHXbi, KaK npaBHJio, I-II cxeneHH, MBJIKO- HUH cpeflHepasMamncTbiH, JKHBOH,
nocxeneHHO HCHesaex B xenenHe 1-2
HucrarMa
HHcxarM BbWBJiaiox, npHflasaa noJioaceHHio xejia GojibHoro
nojioxcHHa: CHAH — c sanpOKHHyxon FOJIOBOH, HaicnoHHB rojiosy K
npaBOMy, jiesoMy nueny; neaca — Ha npaBOM, JICBOM 6oKy, na cnnne, Ha cnane c
sanpOKHHyxoH FOJIOBOH. IlpH .IXOM oiieHHBaKJT, KaK nojiOKCHne xena Bjinaex Ha
HHcxarM: BCJIH HHcxarM HMeexca B pasHbix nojio>KeHHax xejia 6onbHoro H HMCCX
paaHoe HanpasjieHHe, xo HMCCXCS nopanceHHe uenxpajibHoro ox^ejia BecxH6ynapHoro anajiH3axopa; CCJIH HHcxarM HanpasjieH B o^Hy cxopony, HO Menaex CBOK>
HHxencHBHOCXb npn nepeMCHe nono>KeHHS[ xena — 3TO yKasbisaex Ha naxonornio
na6npHHxa; ecnH HHcrarM He nocxoaneH, HanpasnenHe ero pasHoe, xo HMCBX MCcxo naxojiorHH ueHxpanbHoro ox^ena BecxnGyjiapHoro anajiHsaxopa.
XOHHOH KOJIKHCCXBeHHOH H KaHeCXBCHHOH OUCHKH BCCXH6yJMpHbIX Hapy-
Hcnojibsyexca o6teKXHBHaH perncxpauHa HHCxarMa — MeKxpoHHCxaraorpa(j)Ha. 3jieKxpoHHCxarMorpa(})Ha ocHOBana Ha peracxpaixHH KOpHeo-pexHHajibHHX noTCHUHanoB. FnasHoe a6jioKO aneKxpHHecKH nojwpHSOBano: cexHarna sapa-
npo6bi
npo6a. HCXOAHOC noJioaceHHe: pyxn oxseaeHbi B cxopoHbi,
najibLjbi BbinpaMJieHH, ocxajibHbie cxcaxw B KyuaK. Cnanana c ox, saxeM c saKpbixbiMH rjiEisaMH npeAJiararox nauneHxy KocnyxbCH KOHHHKa Hoca no onepeAH yKasaxentHbiMH nanbuaMH o6enx pyK. Oi^euKa: B nopMe
6bicxpo H TOHHO Bbinojmsex saaanne c OXKPHXHMH H c saKpwxbiMH raa. IIpH nopaHceHHH JiaGnpHHxa HagjiiOAaexca npOMaxHBaHHe flByMH pyxaMH B
cxopony, npoxHBononoxcHyio 6bicxpOMy KOMnoHenxy HHCxarMa. Ilpn pexpojianaxonorHH naSiiiOAaexcH HnxeniiHOHHoe ApOHcaHHe pyK.
npo6a (upoSa Eapanu). .HCXOAHOC nonTOKCHHe: naunCHX H span cH^ax nanpoxHB apyr npyra. PyKH naunenxa Jie>Kax na Konenxx, yKasaxenbHbie najibUbi BbinpaMJienw, ocxanbHbie OKaxbi B KyjiaK. PyKH Bpana naxopyKaMH naunenxa na paccxoaHHH OKono 50 CM, yKasaxejibHbie naiibqbi
i, ocxajibHbie c»axw B KyuaK. rionoxceHHe pyK spana H nauncHxa xaKOBO, qxo yKasaxejibHbie nanbubi naqnenxa Haxoaaxca noA nanbuaMH spawa. C
oxKpuxbiMH, saxeM c saKpbixbiMH FJiasaMH nauHeHxy npefljiararox KOCHyxbca yKasaxejibHbiMH najibiiaMH najibqea Bpana. Otfenxa: B nopMC nauHenx Sbicxpo H
XOHHO Bbinojinaex saAanne c OXKPWXBIMH H c saKpbixbiMH ruasaMH. ITpn nopa>KeHHH na6HpHHxa oxMenaexca CHMMexpHHHoe oxKjioneHHe pyK B cxopony, npoxnBonojio>KHyK) 6bicxpoMy KOMnonenxy HHCxarMa. Opn nopaaceHHH MO35Ke4Ka na6jiiOAaexca npOMaxHBaHHe OAHOH pyKH na cxopone nopa>KeHHa.
FlpoGa orKJioiieimn pyK (npoGa BoaaKa-OHinepa). HcxoAHoe nojio*eHHe: naiiHCHX CHAHX, Bbixanya pyKH BnepeA na ypoBHe njien. YKasaxeAbHbie
najibijbi BbinpaMJienbi, ocxajibHbie cacaxw B KyuaK. Bpai ycxaHaBUHBaex CBOH
yKasaxejibHtie najibuu MaKCHMajibHO GJIHSKO K najibijaM naiineHxa, HO He Kacaexca HX. Fjiasa naunenxa saKpbixbi. OifeHKa: B HopMe nauneHx yAepjRHBaex 3aAaHHoe nojio»ceHHe. Flpn nopaaceHHH JiaOnpHnxa na6jiK)Aaexca oxKJioHCHHe
o6eHX pyK B cxopony, npoxHBonoJio^cHyro 6bicxpOMy KOMnoHenxy HncxarMa.
IIpH naxojrorHH saAHeH nepenHOH aMKH oxioiOHaexca OAHa pyKa na cxopone
nopa«eHHa.
4na40XOKHHe3. HcxoflHoe noJioacenHe: pyKH nauHenxa Bbixanyxbi Bnepea
na ypoBHe njien. Bpan npocHX naunenxa npOH3BOAHXb ABHxceHne pyKaMH —
npoHauHio H cynHHaiiHio. OifeHKa: B nopMe ABH^ceHHa o6enx pyK CHMMCXPHHHbi. ripn nopajKCHKH MO3>KeHKa HaSjiiOAaexca pe3Koe oxcxaBaHHe na cxopone
nopa>KeHHa.
86
Teivia V. YXO: BECTMByjlflPHblfl AHAHH3ATOP
npo6bi
IlpH npOBCflenHH npo6 span oSasaxejibHO naxoflHxca paflOM c nauHenxoM H
cxpaxyex ero.
Floia Pow6epra. HcxoflHoe nojioaceHHe: nauHenx CTOHT, IMXKH H HOCKH cxynHCH cABHHyxbi BMecxe, pyKH Bbrranyxbi Bnepefl na ypoBHe IUICH, ruasa oxicpbixbi.
3axeM nauHCHT saKpbraaex raaaa. OifenKa: B HopMe nauHCHx ycxoHHHB B sa^aHHOM
nojioxceHHH. IlpH nopajKCHHH JiaGnpHHxa GojibHofi oxioiOHaexca B cxopony, npoxnBonojio3KHyio 6bicxpOMy KOMnoHenxy HHcxarMa. FIpH HSMCHeHHH nojioaceHHa roxaioKe Ha6nK>flaexcfl HSMeneHHe HanpaBJieHHa nafleHHa — Bcer.ua B cxopony
KOMnoHCHxa HHCxarMa. IIpH nopa*eHHH M035KCHKa naunenx OXKJIOHHexca HJIH naaaex B cxopony nopaaccHHa. /laHHyio npo6y MOHCHO ycjioacHHXb.
Ccncn6njiH3HpOBaniibiii PoiuSepr. Cxox B nose PoMSepra c saKpbixbiMH
raaaaMH naqHenx cxaBHX oany nory BnepeflH Apyrofi, rax, nxo6bi n«XKa Kacajiacb
HocKa. B HopMe nauHCHT coxpanaex ycxoHHHBocxt B sa^aHHOM nonoxceHHH.
Xo.ibGa no npuMoii JIHHHH Bnepea H Hasafl. C oxxptixbiMH, a saxeM c saKpbiXWMH raasaMH naimenx naex no npaMOH JIHHHH. B HopMe 3x0 ne cocxaBJwex rpy^a.
Ilpn nopaxenHH JiaGnpHHxa HflymHH oxKJioHHexca ox npHMOH JIHHHH B cxopony,
GwcxpoMy KOMnoHenxy HHcxarMa. OpH nopa»enHH MO3«eHKa
x, maxaacb, uiHpoKO paccxaBJiaa Horn, na^aer Ha cxopony nopaaceHHH.
noxoaKa — noxoflKa npncxaBHbiMH uiaraMH GOKOM no npaMoft
JIHHHH. B HopMe H npH nopaxceHHH Jia6npHHxa HcnoJiHaexca HBXKO, yBepeHHO.
Hpn nopaaceHHH MosaceHKa nauneHX HC MOXCX BbinoJiHHXb sa^aHHe B cxopony
3KcnepnMeHTanbHoro HMCTarwia
Ilpn HccjieAOBaHHH BbisBaHHoro (3KcnepHMeHTajibHoro) HHcxarMa neo6xoynnxbiBaxb saBHCHMOcxb HanpaBJieHHfl HHcxarMa ox HanpaBJieHHa c^BHra
3H/iojiHM(J)bi B HCCJie^yeMOM nojiyKpyncHOM Kanajie. 3xo HBJieHHe 6bmo onncano
B KOHue XIX — Hanajie XX seica ynenbiMH 3BajibflOM H BoaneKOM H c(J)opMyjiHpOBaHO B BHflC <OKeJie3HbIX» 33KOHOB:
3aKOHbi 3eanbda:
1 . B ropH3OHX3JibHOM nojiyKpy»HOM Kanajie ABH^CCHHC SHflOJiHM^H ox rjiaflKoro KOHua K aMnyjie BbisbiBaex HHCTarM B cxopoay pa3/ipa>KaeMoro yxa.
2. /Jjifl ropH3OHxajibHoro nojiyKpyacnoro Kanajia ABH»ceHHe SHijojiHMcfibi K
aMiiyne (aMnyjionexajibHbiH XOK) asjiaexca Gojiee CHJibHbiM pa3flpa»HxejieM,
3HflOJiHM(J)bi ox aMnyjibi (aMnyjio4)yrajibHbiH XOK).
3. JJjia BepxHKajibHbix KanajioB SXH saKOHbi o6paxHbie.
BaxoHbi BosmeKd'.
1. HncxarM Bcer^a npoHcxoanx B HJIOCKOCXH BpameHHa.
2. HncxarM Bceraa npoxHBonojioxceH c^BHry 3Hflo;iHM(J)bi.
I. <t>M3MOJiorna BeCTn6y.napHoro aHa/iMaaiopa. Meroflbi
87
BpaiuarejibHan npo6a. npH BbinojineHKH BpamaxejibHon npo6w
exca peaKUHa jia6HpHHxa Ha aACKBaxHWH pasflpa>KHxejib — yrjiosoe ycKopeHHe,
HXO MOHCHO OXHCCXH K npeHMymecxBaM aaHHoft npo6w. OaHaKo, Hxo6bi npaoueHHXb nojiyneHHbie BCcxnGyjiapHbie peaKUHH, cjieayex noMHHXb, HXO
noflBepraioxca o/jHOMOMenxHO npaBbiii H jiesbiH yiimbie Jia6npHHXH, a xaioKe Moryx BOSHHKaxb BbipaxceHHbie npoasjieHHa BerexaxHBHbix H coMaXHHCCKHX BecxH6yjiapiibix peaKUHH (paoxa, naACHHe c Kpecjia, peaKoe CHH>KeHHe
apxepnajibHoro aaBJieHHa, TaxnapHXMHH H x. a.). Bcjieflcxsne sxoro HccneziOBaHHC SKcnepHMCHxanbHoro nocxspamaxejibHoro HHcxarMa BOSMOKHO xojibKo y
JIHH, HC HMeiOUIHX >K3JIO6 Ha B6CXH6yjiapHyiO OTC(J)yHKUHK).
TexHHKa Hccjie^oBaHHa ropHsonxajibHoro nojiyKpy>KHoro Kanajia: nauHenxa
yca»CHBaiox B Kpecjio BapaHH. /],Jia nepeMemcHHa ropHsonxajibUbix nojiyKpyHcHWX KanajiOB B ropHSOHxajibHyio njiocKocxb HaKJioHarox rojiOBy HCCJieayeMoro
enepea na 30°. Fjiasa saicpbixbi. HpoHSBoaaT BpameHHe Kpecna co CKOpocxbio
10 o6opoxoB sa 20
uccnedoeanusi npaeozo zopu30HmajibHozo
HOZO KdHcuia epaufenue npoeodnm npomue tacoeou cmpejiKU. fljix uccjiedoeauufi jieeozo zopusonmanbHozo Kanana —
no Hacoeou cmpejiKe. Kpec/io pesKO ocmanaejiueaiom u uccnedymm nucmazM. IJocmepanjamejibHbiu nucmazM nanpaenen e cmopony uccJiedyeMOZO Kanojia (pasdpaoicaeMOzo yxa). Mccjiedoeanue zopusonmajibHozo Kancuia dpyzou
cmopoHbi DicejiamejibHO npoeodumb nepe3 15-20 Mimym.
BepxHK3JibHbix KanajioB npoBOflnxca aHajiornHHO, HO, coraacHO saKonaM BoaneKa, aim HCCJie^oBaHHa <J>pOHxajibHoro Kanana rojiOBy HCCJICayeMoro Hywno HaioioHHXb snepefl Ha 90°, a fljia HccjieaoaaHHH caraxxajibHoro
Kanajia — na 90° K njieny. OtjeHKa HHcxarMa npoBoanxca corjiacno xpexbCMy saKony Ssajibaa.
JiaSnpHHxa oueHHBaiox no npoflOJiacHxeJibHOCXH HHcxarMa,
Koxoporo B HopMe 25-30ceKyH.il. HMCCT snaneHHe cpaBHCHHe
nocxBpamaxejibHoro HHcxarMa cjiesa H cnpasa.
npeccopnaa npoSa npHMenaexca fljia BbiaBJieHHH 4>HcxyjibHoro CHMnxoMa.
Oncxyjia jia6HpHHxa — KOCTHUH CBHIIJ, o6pa3OBaBuiHHca BCJie^cxBHe Kapneca KOCXHOH cxeHKH yiiiHoro Jia6npHHxa npH cneqHtjjHHecKOM HJIH HecneuH(J)HHeCKOM BOcnajiHxejibHOM npouecce. Ilpn SXOM HSMCHCHHe aasJieHHa B napyjKHOM
cjiyxoBOM npoxoAe H cpe^HCM yxe 6yaex Bbisbmaxb CMemeHHC cpea BHyxpeHHero
yxa H pasApameHHe eecxHSyjiapHbix peqenxopoB.
TexHHKa npOBefleHHa: nneBMaxHHecKHM 6anjiOHOM DoJiHuepa HJIH Ha^aBJiHBaHH6M H3 KO36JIOK yiUHOH paKOBHHbl nOBblUiaiOX flaBJICHHe B HapyjKHOM CJIyXOBOM
npoxoae. ECJIH HMeexca 4>HCxyjia JiaGnpHnxa, xo BOSHHKaex HHCxarM B cxopony HCyxa; npn noHH»eHHH ^aBJieHHa nncxarM HanpaBJien B cxopony nepas-
(TeMa V. VXO: BECTMSyjlflPHbll/1 AHAT1M3ATOP
88
flpa>KaeMoro yxa. Hnoraa HHcrarM He BosHHKaex, HO nauHCHX onHCWBaer noHBJieHHe
OtUymeHHH TOIUHOTH, FOJIOBOKpyHCeHHH
CyGtCKTHBKblH (JjHCTyjIbHblH CHMHTOM.
Ka.iopH'iccKan npoiia — HccneflosaHHe HHCxarMa npn xeiunepaxypHOM
BOS/ieHCTBHH Ha 6apa6aHHyio nepenoHKy. HpoOy neubsa npOBo/nixb npn ocxpOM
BOcnajieHHH Hapy>KHoro H cpeanero yxa, paapwBe 6apa6aHHOH nepenoHKH, ymHOM KpOBOXeHCHHH H JIHKBOpee. IIpH XpOHHHCCKOM THOHHOM Cpe^HCM OTHTC
BO3MO5KH3 KajIOpH3aU,Hfl BO3flyXOM HUH CXCpHJIbHblM paCTBOpOM. IIpo6a IIO3BOJIfl-
ex oneHHBaxb HsoJinpoBaHHO npaBbifi H HCBMH yuiHOH jiaSnpHHX H MOHCCX 6wxb
npOBe/ieHa 6onbHbiM B TH^KCJIOM COCTOHHHH. IlpH KanopHsaqHH ropaneH BOAOH
noHBJixexcH HHcxarM B cxopony HccjieflyeMoro yxa. IIpH HcnojibsOBanHH XOJIOAHOH BOflbi HHcrarM HanpaBJieH B npoxHBonojiWKHyio cxopony. nojio5KCHHe nauHewxa npH Hccjie/iOBaHHH — neaca HUH CHRX, c sarrpOKHHyxon na 60° nasaa FOJIOBOH, HccjieflyeMoe yxo HaioioHeHO KHwsy. Kajiopimecxafi npoda no Ko6pavy: B
HCCJieayeMoe yxo BUHBarox 5 MJI JIC/IHHOH (1-12°C) BOJIH. B HOpMe nepes
10 ceKynji (naxcHTHbiH nepHoji) noHBnxexca HHcxarM H npoflOJiacaexca B xeneHHe
15-lOOceKyH^ (^nHxejibHOCXb HHCxarMa). KajiopimecmH npo6a no EjiazoeeufencKOu: BUHBaHHe B Hccjie/iyeMoe yxo 100 MJI BO/ibi xeivinepaxypbi xena ±12 °C
aa lOceKyHfl. B nopMe Hepes 25-30ceKyna noaBiwexca HHcxarM flUHxejitHOcxbK) 70-90 ceKynzi. fijix Boa^yuiHOH KanopHsainiH HcnoJibsyiox sosayx t = 25 °C
H 60 °C co CKOpocxbio noxoKa 6 JI/MHH B XCHCHHC 1 MHHyxbi.
jiaxeHXHoro nepHo^a H/HJIH yMCHbiueHHe anHxenbHOCXH HHCxarMa
Ha noHroKCHHyio BoaSyjiHMOcxb BecxnGyjiapHoro aHajinsaxopa. Bonbuiaa
npOAOJDKHxejibHocxb HHCxarMa yKaawBaex na noBbnuemiyio BO36y/jHMOCXb BecxnGyjiapHoro aHanHsaxopa H Hepe^KO yKasbisaex Ha naxononno sajiHCH nepenHOH SIMKH.
^na npoi})ox6opa H MC/JHUHHCKOH 3KcnepxH3H Hcnojibsyexca HCCJie/iOBaHHe
OXOJIHXOBOH 4>yHKH,HH.
OTOJiHTOBaa npoSa BoHMCKa. Hcxoanoe noJio>KeHHe — GOUBHOH Haxo/jHXCH B Kpecne BapariH, xyjioBHme HaKnoHCHO Ha 90° Bncpefl, r^asa saKpbixw. IlpoBO^Hxca 5 BpaujeHHH sa lOceKyH^. Kpec.no pesKo ocxanaBUHBaiox, BbixcHjjaiox
5 ceKyna (GojibHoM HaxoflHTca B HCXO^HOM HOJIOHCCKHH), saxeM npeanarawx
6onbHOMy oxKpwxb raasa H BbinpaMHTbcn B Kpecjie. OueHKa OXOJIHXOBOH <j)yHKUHH npOBO^HXCH HO B03HHKaK)m,HM COMaXHHCCKHM H BCrexaXHBHblM peaKU,H8M:
CxeneHb
0
1
CoMaTHHecKHe peawmH
BereTaTHBHbie peaKUHH
OrioioHeHHH Hex
OxcyrcxBHe BerexaTHBHbix paccxpoficxB
OxKnoueHHe xyjiOBHma ox Bep- CySteKXHBHbie omymeHHa (roJioBOKpyTHKOJlbHOH OCH Ha
0-5°
5K6HHe, TOUIHOxa)
4 2
OxKJioHCHHe xyjiOBHma ox sep- Ilo6jie4HeHHe HJ1H nOKpaCHBHHe KO5KH
XHKanbHOH OCH Ha 5-30°
jiHua, HSMCHCHHe apxepnajibHoro aas-
3
FlafleHHe (HCCJieayeMWH He y/rep- HsMeneHHe /teaxejibHOCTH cep^eHHO-coWHBaex xejio B BepxHKanbHOM no- cyflHcxofi H flwxaxenbHOH CHCXCM, psoxa
JlCHHa, HCC, MJW H T. n.
JIO5K6HHH)
II. 0M3MOJiornfl BecTn6ynnpHoro aHannsaropa. Mexoflbi
89
BecxnSyjixpHoro anajTHsaxopa y npaKTHnecKH
sflopoBoro HenoBCKa: cnoHxaHHbix BecxH6yjiapHbix paccxpoficxB Hex, BOsSyflHMocxb BecTH6yjinpHoro annapaxa cHMMexpHHHa, HopMajibHa.
A npn HajiHHHH naxonorHH, HanpHMep, ocxporo jiaGnpHHXHxa cnpasa, BCCXH6yjwpHbie paccxpoKcxBa MTOKHO onHCbmaxb cjie^yiomHM o6pa30M. Cy6T»eKXHBHbie
omymeHHa: CHH>KeHHe cjiyxa cnpasa, xouiHoxa, Bpamaxejibnoe rojioBOKpy«eHHe,
ycHJiHaaiomeeca npH nepeMene nojioaceHHH rojiosbi, cJia6ocxb, nepnojiHHecKH —
cepfliie6HeHHe. SNyHR-2, MCHBOH, MejiicopasMaiiiHCXbiH. KanopHHecKHH HHcxarM
no BjiaroBemencKOH (25°): cnpasa: — jiaxenxKbifi nepnoa — 10 c, .OJIHX. HHCxarMa — 70 c, cjiesa — JiaxeHXHbiH nepHO^ — 25 c,OTHX.HHCxarMa — 70 c. B nose
PoM6epra naGjHOAaexca oxKjiOHCHHe xyjiOBHma BJICBO. MapiueBaa xoflbSa — oxKJiOHeHHe BJICBO. OjiaHTOBafl noxoflKa — BbinojiHsex. B najibue-najibueBOH npo6e
H npo6e BoAaKa-<t>Hiuepa Ha6jnoAaexca conexaHHoe oxKJioneHHe pyK BJICBO.
Bonpocbi HToroBoro KOHTponn 3H3HMM no rewe V
1. MTO fls/ifieTCfl afleKBaTHbiw pa3flpa>KHTe^eM p,nt\o
aHa/iMaaropa?
2. KaKne Bbi anaexe HeafleKearHbie pa3flpa>KMTenM BecTn6ynnpHoro
aHannsaiopa?
3. KaKMe TMnw BecTn6ynflpHbix peaKquii BH anaexe?
4. Hxo osHanaex noHnxne «HncxarM»? KaKne npunnHbi Moryr
HMcrarM?
5. OxapaKxepnayiixe na6npnHXHbiii HMcxarM.
6. KaK asynax aaKOHbi
7. KaK asynax aaKOHbi
8. riepeMMcnuxe KOopflMHaqnoHHbie npo6bi. KaK BbinonHaex
HaqMOHHbie npo6bi 6onbHOM c nopaweHMeM na6npHHTa?
9. FlepeHMCJiMxe cxaxo-KMHexMHecKMe npoSbi. KaK BbinonH^ex cxaroKMHeTMHecKne npo6bi 6onbHOM c nopajKeHneM na6npHHxa?
10. KaKMM nauHeHxaM nenbsa nposoflnxb BpamaienbHbie npo6bi?
I. KnuHMMecKaa anaTOMnsq ropraHM
91
. OcBeTurenbHbie npuSopbi: MCTOHHMK csera, no6Hbiki pecpneKrop, orocKon, napuHrocKon, BonoKOHHaa onrnKa.
Ha6op MHCTpyweHTOB. Hocosbie sepKana, Lunarenn, yiiJHbie BOPOHKM, ropraHHbie M HocornoTOMHbie sepKana, sonflbi HasMBHbie, nHHqeibi yiiiHbie, nnHLieibi
HOCOBbie.
Pa6osee wecjo. MHCTpyMeHTaiibHbiM CTOJIHK, HacronbHaa jiaMna, cnnproBKa, flsa cryna.
Mecro npoeefleHMfl aaH^TMfi. VneGHa^ KOMHara.
ervta VI.
AHATOMO-OM3MOJlOrHHECKME
OCOBEHHOCTM TOPTAHM
Bpeufl aaHHTkm — 180
Ue/ib aaHflTMfl. OGtacHMTb nponcxo>KfleHMe nan6onee nacxbix CMMPTOMOB aaBoneeaHMii ropxanM Ha OCHOBaHnn 3H3HMM HOpManbHOM M TonorpacpMHecKoii anaxoMHH OpraHOB WeM. nOSHaKOMMTbCH C 4>M3MOJlOrO-CpOHeTHMeCKMMM OCO6eHHOCXHMM CpOpMHpOBaHMH
OCO6eH-
HOCTH ropxaHM.
2. BbiflenHTb Ha ocnose TonorpacpMM ropxaHM BOSMOJKHbie npMHMHbl HapyweHMH nOflBM>KHOCTH MCTHHHblX
ronocoBbix cicnaflOK.
3. 3aKpennib nasbiKM npoeefleHna HenpaMoti JiapnHorocKonnn.
4. HsynnTb ocoSeHHOcru flbixanup BO spewa pesH,
5. FIOSHaKOMMTbCJI C TMOaMM HOflaMM TO/IOCa.
6. flosHaKOMMTbCfl c flBMw
MycKynarypbi BO speivifl penn.
flonofiHumenbHo dna neduampuvecKoao
(paxynbmema:
7. 06oCHOB3Tb H3 OCHOBaHMM aHaTOMO-C(3H3MO^OrM-
MecKMX oco6eHHOCTeii ropraHM oco6eHHoc™
BocnanmenbHbix saSonesaHMM ropraHM y flereM
luero Boapacia.
ripu nodaomoeKe K sanamuio noemopumt,
c npeduiecmeytomux Kypcoe:
Ms Kypca HOpMajibnoii anaTOMMM — xpniun M CBJISKM, MbiaieHHbiM annapai ropraHM.
Ms Kypca ronorpacfjMHecKOM anaTOMMn — KnerMaroMHbie npocrpaHCTBa oien, ronorpacjjmo opranoB rpyaHOM
l.Condamoe M. 5. JleKquM no OTOpuHonapuHrojiornn. — M.:
1990.
" 2. LUeepbiauH 5. B. PyKOBOflCTBO no flercKOM OTopMHonapuHronornM. — M.:
MeflnqnHa, 1985.
3. flMumpueHKO M. Arnac KnMHMMecKoii aHaroMMn
MocKBa, 1998.
I. KJlMHMHECKAfl AHATOMMfJ TOPTAHM
TopxaHb (Laryngs) — nojiwii opran BepxHHx fluxaxejitHtix nyrefi,
H«K>mHH ropxaHoraoTKy H xpaxeio, HMeromHH B OCHOBC xpameBOH CKCJICT, o6jiarojiocooSpaayiomHM MbiuienHbiM annaparoM.
ropxaHH no OTHOiiieHHio K meHHbiM nosBOHKaM saBHCHT ox nona H
Boapacxa. V aexefi H xcenmiiH ropxanb pacnonaraexca Bwuie, HCM y MyacHHH H JIHII
no>KHjioro Bospacxa. Y HOBOpoJK^eHHoro sepxHaa rpaHHqa ropxaHH naxo^Hxca na
ypoBHe xena II uieHHoro nosBOHKa, HHJKHaa — na ypOBHe III-IV uieHHbix nossoHKOB. K 7-H roflaM ropxanb necKOJibKO onycKaexca: BepxHaa rpaHHua — no IV
meHHoro nosBOHKa, HHHCHHH — flo VI uieHHoro nosBOHKa. B xeneHHe BCCH nocneflyromeH TKHSHH coxpaiwexca TetmeHUHH K /lajibHeHiueMy onymeHHio ropxaHH: y
Bspocjiwx ropxanb pacnojiaraexc» na ypoBHe V-VI meftHbix HOSBOHKOB, y IIOHCHna ypoBHe V-VII uieHHbix no3BOHKOB. OCHOBV ropxaHH cocxasjiaex
, pasMep Koxoporo H, oco6eHHo, saflHaa nuacxHHica c BospacTOM SHaHHxenbHO yBenHHHBaexcH. FopxaHb ManbHHKOB H aeBOHCK £0 3-x nex O/IHnaKOBa. riocne 6-H Jiex ropxanb MajibHHKOB pacxer 6bicxpee. B nepHOfl nojioaoro
cospesaHHs ropxanb MajibHHKOB yBenHHHBaexca na 2/3 CBOCH flJiHHH, a /jeBoneK^ —
na 1/2. B 3x0 nee BpeMa y ManbHHKOB Ha6jiK)4aexca Myxaqua rojioca. MyxaqHs ronoca HMCCX Mecxo H yflCBOHCK,HO Bbipaxcena B MeHbiuefi cxenenH. FOJIOC noHH>Kaerca y ManbHHKOB na OKxasy, yflCBOHCK— Ha ppa xona. 3xH HSMCHCHHa npoHcxoaax nocxeneHHO B xeneHHe 2 -3-x nex, HO Moryx Sbixb nepnoflbi pe3Koro, «CKaqKOo6pa3Horo» noHH»eHHfl ronoca B xeneHHe necKOUbKHX MecaueB. BospacxnbiMH oco6eHHocxaMH ropxaHH flexefi paHHero Bospacxa o6t«CHaexca aBucHne Bpocxpn^opa ropxaHH. BpoxyieHHbiH cxpn^op ropxaHH — xpanaiyHH
K, noflBJiaiomHHCfl Ha Bfloxe. TeM6p uiyMa npn ynameHHOM ^wxaHHH cxano-
92
TeMa VI. AHATOMO-OHSHOnorHMECKHE OCOEEHHOCTH TOPTAHM
BHxca 6ojiee BHCOKHM, HanoMHHaex BopKOBaHne ronyGen, MypubiKanbe KOUIKH.
Bo BpeMH cna myM yMCHbiuaexca. Bpo>KfleHHbiH cxpH^op He conpoBoayiaexca
, ronoc pe6eHKa SBOHKHH. BosHHKaex BpoxyjeHHbiH cxpn/jop Ha 2-3-fi
5KH3HH pe6eHKa, Hcnesaex Ha 2—3 -M ro,zry >KHSHH. IIIyM Ha B^oxe cnaqajia
nocxoHHHblH, saxeM noasjiaexca nepHoaHnecKH, saxeM ncnesaex BOBCC. XpanamHii 3ByK noaBjiaexca npH npojiaGnpoBaHHH jienecxna najiropxaHHHKa B ropxaHb
H KOJieSaHHax HepnanoHaflropxaHHbix cmiaaoK BO BpeMa Bfloxa. HoAo6Hbie ^BH5K6HHH BO3HHKaK>X H3-33 HCSpCJIOCXH XpamCBOH XKaHH H HH3KOFO XOHyCa CBH3O4-
HO-MbiiueHHoro annapaxa ropxann, qxo o6ycnoBJiHBaeT noswuieHHyio Maraocxt
ropxaHH. HcKOiopbie Bpann pacu,eHHBaiox BpoaqieHHWH cxpn^op Kax pesyjibxax
napHHroManauHH, qxo, no BCCH BHJHMOCXH, ne COBCCM npaBHUbno. JlapHHroMajiau,Ha (pasMarneHHe ropxaHH) — sxo cjieacxBHe naxonorHHCCKoro npouecca.
Cueayex ynnxbisaxb, HXO BpwiyieHHbiH cxpn^op — ne naxojiorHH, 3x0 cocxosHHe
BpeMCHHoe H HC xpe6yex jieneHHa. Cnoco6cxBOBaxb BOSKHKHOBCHHIO BpoayjenHoro cxpHflopa MOJKCX HeaoHOiiieHHOCXb rnio^a, saaep^Ka cospesaHHa XKaneH na
<J)OHe BHyxpHyxpoGHOH THIIOKCHH ruiofla HJIH BHyxpHMaxoHHOH HHC^CKUHH. Ofl3XH (j)aKxopbi flaneKO HC Bcer^a cnoco6cxByiox noflBJieHHK) Bpo»yieHHoro
Fopxanb COCXOHX H3
CB«3KaMH, cycH MbimuaMH (CM. PHC. 8 IIpHii05KeHHa). Bsepxy ropxaHb
Kocxbio, BHH3y — CBSSKOH c xpaxeeft. C 6oKOB ropxanb XCCHO csasana c KpynnbiMH cocyflHcxo-nepBHbiMH nyHKaMH
men, B cocxaBe Koxopwx naxoflaxca: oSmaa cojnjiaajipxepH^BjrjTTjeHHaa apeM_HaaBeHa 1 6jrvyaaromHH H CHMnaxHHecjcHH nepBH. Csa^H sa BXOAOM B ropxaHb
HaxoflHxca ropxanoritoxKa, Ha ypOBHe nepcx3e~BHjHoro xpama — BXOJI B nnme5, ynacxoK meHHoro oxflejia nnmeBOfla. BnepeflH ropxaHb rpaHHinx c Mbirnmen, K 60KOBWM noBepxHocxaM mnxoBH^Horo xpama npraieacax flOJiH IUHXOBH/IHOH >KCJie3bI.
Fopxanb — opran naccHBHO noflBH»cHbiH. Bo speMa rjioxaHiia, nenna ropxaHb coBepmaex ^BH»ceHHa BBepx-BHH3 6naroflapa coKpamenHK) uieHHbix Mbimn
H Mbimu raoxKH. Hpn npOH3HomeHHH BbicoKHX 3ByKOB ropxaHb noflHHMaexca,
HH3KHX — onycKaexca. BOSMOHCHO naccHBHoe ABHHceHHe ropxaHH BjieBO-BnpaBO,
npH SXOM npOHCxo^HX KpennxauHa xpameft ropxaHH.
* B cxpoeHHH CKenexa ropxann Bbiflejiaiox xpn nenapHbix (nepcxHCBHAHbiH,
HaAropxanHbifi) H xpn napnbix (nepnanoBHaHbie,
xpama. OCHOBOH CKejiexa ropxaHH as^aexca
xpam (cart, cricoidea), pacmnpeHHaa njiacxHHa Koxoporo oGpamena KsaflH, a ysKaa ffyra. — Knepe^H. Ha GOKOBHX nosepxHocxax xpama naxoaaxca cycxasHbie
AJia nepiiajiOBH^Hbix xpameii — BBepxy H jyw HHHCHHX poroB mHxoxpama — BHHsy. Haa nepcxHeBH^nbiM xpaiyoM pacnojiaraexca caMbiH
6ojibiuoH xpam ropxaHH — mnxoBH^HbiH (cart, thyreoidea). BepxHHe pora mnxoBHjjHoro xpama coe^HHaioxca c noflT.a3biHHOH Kocxbio, HHacHne — c nepcxne-
I. K/iMHUHecKan aHaroMnn ropraHM
93
xpainoM. Yron mnxoBH^Horo xpama (KaflWK, AJJEMOBO aGnoKO, pomum
Adami) noKpbix xoubKO KO^CH H (jjacqHCH, y My^KHHH 3H3HHxe^bHO Bbi^aexca na
nepeAHefi noBepxHOCxn IIICH. B cxpoeHHH na/iropxaHHoro xpama
cart, epiglottica) Bbiflenaiox cxe6ejib (petiolus) H nenecxoK. Cxe6e;ib
HHKa cBasKOH npHKperuieH K BHyxpeHHCH noBepxnocxH yrna mnxoBH^Horo xpama y BepxHCH BbipesKH. JlenecxoK Bbi^aexca B ropxanorjioxKy H orpaHH^HBaex
BXOA B ropxaHb. Y aexen jienecxoK na/iropxaHHHKa nacxo CBepnyx c GOKOB xaK,
HXO Kpaa ero 3aBepnyxbi KHH3y, BOSMO^CHO coxpaneHHe xaKoii <J)opMbi H y B3pocjibix. Bo BpeMa raoxanna ropxaHb no^KHMaexca KBepxy, JienecxoK HaaropxaHHHKa onycKaexca, H xaKHM oSpaaoM BXOA B ropxaHb nepeKpHBaexca, H
KOMOK nocxynaex B nnmeBOA- nepcxHeBH^HbiH, mHXOBHjiHbiH H
xpamn asjiaioxca rnanHHOBbiMH.
HepnajioBHflHbie xpamn (cart, arythenoidea) ocHOBaHHCM Kpenaxca K cycxaBHOH
noBepxHocxH raiacxHHKH nepcxHCBHjmoro xpama, BepxyuncH nanpaBJieHbi BBepx. Ha
ocHOBaHHH Kaacaoro H3 xpamen HMeroxca flBa oxpocxKa — roJiocoBOH (processus
vocalis) H MbiuieHHbiH (jiaxepanbHbiH, processus muscularis). FojiocoBon oxpocxoK COCXOHX H3 sjiacTHHCCKoro xpama, MbimenHbrii oxpocxoK -7— HS raajiHHOBoro. K ronocoBOMy oxpocxKy Kpennxca ronocoBaa Mbiuma, saneraiomaa B rny6HHe HCXHHOH rojrocoBOH CKJiaAKH. K MbiuieHHOMy oxpocxKy — Mbiumbi, OKHMaiomHe H pacuinpaiomHe romeJib. Po>KKOBHAHbie xpamw (cart, corniculalae) pacnojioxcenbi na/i BepxyuiHepnajiOBH4Hbix xpamen B xonme qepnajioHa/iropxaHHbix CKJiaflOK. HecKonbKO
ox po5KKOBHflHbix xpamefi B xonme xex 5Ke HepnanoHanropxaHHbix
Haxoflaxca KHHHOBHmn>ie xpamn (cart, cuneiformes). HepnanoBH^Hbie,
H KUHHOBHAHbie xpamH asjiaioxca snacxiraecKHMH.
HsMCHCHHe npocsexa FOJIOCOBOH (flbixaxenbHoft) mejiH, a xaicace
HHe/paccJia6neHHe ronocoBbix CKJia/joK nponcxoanx 6naroAapa ABH»<eHnaM B
cycxasax ropxaHH: nepcxne-mHXOBRaHOM (sBWKemui Bnepe^-Hasaa) H nepcxneHepnajiOBHflHOM (BpamaxejibHbie, HaicnoHHbie ^BHaceHHa HepnajioBH^Hbix xpamen).
K BHyxpeHHefi nosepxHOCTH xpamen ropxaHH npHJieacHX (JmGpo-sJiacxHHecKaa
Ona COCXOHX H3 flByx Hacxeii: HexbipexyrojibHaa MCMBpana, BepxHHH
KoxopOH Bbicxynaex B BHAC HepnajionajiropxaHHOH CKJia/iKH, a HHJKHHH (J)opMHpyex ocHOBy JIOWHWX ronocoBbix CKJiajjoK (cmiaziOK npeaHBepna), H 3JiacxHHeCKHH KOHyC, BCpXHHH KpaH KOXOpOTO npe^CXaBJiaCX CO6OH HCXHHHyK) rO^OCOByiO
CKJiaaKy, a HH>KHHH (])opMHpyex nepcxHe-mnxoBHaHyio (KOHHHCCKyio) csa3Ky. PacceneHHe KOHHHCCKOH CBasKH (KOHHKOxoMHa) — onepauHa Heoxjio>KHOH noMomn
npn ocxpOM cxenose ropxaHH B cxa^HH accjjHKCHH, Bbmojinaexca B 3KcxpeManbHbix
(BHe6onbHHHHbix) ycnoBHax. ^annaa onepanna cnacaex »H3Hb H nosBouaex xpancnopxHpOBaxb 6ojibHoro B cxauHonap, r^e Sy^ex npOBCflena xpaxeocxoMHa.
Mbiumu ropraHH. Mbimuw ropxaHH pas^ejiaiox na ase rpynnbi: napy>KHbie
Mbimubi, oOycnaBJiHBaiomHe flBHHceHHe ropxaHH B UCJIOM, H BHyxpeHHHe Mbimnbi, HSMcnaiomHe npocBex TOJIOCOBOH menH H cxenenb HaxaxccHna ronocoBbix
94
TeMa VI. AHATOMO-<DM3HOJ1OrHMECKHE OCOEEHHOCTH fOPTAHH
Hapymibie Mbiumti ropxann .aenaxca na .ZTBC rpynnw: 1) HenocpeflcxBCHHO
Kpenamneca K ropxanH (m. m. sternothyreoideus, thyreohyoideus) H 2) KpenaujHeca K iio,ui>}i3biHHOH KocxH H Bbi3biBaK>m,He onocpeflOBaHHoe BjmaHHe na .IJBHHCCHHC ropxaHH (mm. sternohyoideus, omohyoideus, stylohyoideus, digastricus).
BnyxpeHHHe Mbiumbi ropxaHH aejiax na nexbipe rpynnbi:
I — Mbiumbi, HSMenaiomHe nonoaceHHC
II — Mbiumbi, cymisaiomHe rojiocoByro
III — Mbimubi, pacuiHparomHe ronocoByio
IV
I. KnMHMMecKafl anaxoMnq ropxaHn
95
Horo xpama H npHKpeiuiaexca K MbimeHHOMy oxpocxKy HepnanoBH^Horo xpama. Dpn
ee coKpameHHH MbimeHHbie oxpocxKH nepnanoBH/mbix xpamefi oxxo^ax raaOH. 3to)
npHBOflHx K xoiny, HXO rojiocoBbie oxpocncH BMCCXB c ronocoBbiMH CKnafljcaMH OXXOAHX
B cxopOHbi jiaxepanbHO, B pesyubxaxe wero ronocoBaa menb paciunpaexca.
K IV rpynne oxnocaxca Mbiumbi, HSMenaromHe Haxa^KCHHe ronocoBWX CKna^OK:
— m. cricothyreoideus (anticus) npHKpenjiaexca O/IHHM KOHUOM K ayre nepcxHCBHflHoro xpama, ^pyrHM — K HHacHeii noBepxHocxn mHXOBHflHoro xpama.
Flpn coKpameHHH naKJionaex mnxoBHAHWH xpaiu Bnepea H HararHBaex ronoco-
MMIimbI, HSMCHaiOmHe HaXHTKCHHC FOJIOCOBblX CKJiaflOK.
K I rpynne oxHOcaxca:
— m. aryepiglotticus (napnaa), nanHHaacb ox HepnanoBHflHoro xpama, snuexaexca B 6oKOByK> nosepxHocxb Ha^ropxaHHHKa, oGpasyex HepnajionaflropxaHnyio cKjia/jKy. IlpH oAHospeMeHHOM coKpameHHH cyacHBaex Bxofl B ropxaHb H
npejmBepHe ropxaHH, oxxaraBaex Ha^ropxaHHHK KHHay, saicpbreaa BXOA B ropxanb npH aKxe rnoxaHHa;
— m. thyreoepiglotticus Ha™naexca ox BHyxpeHHCH nosepxHocxH yrna IUHxpama H npHKpenJiaexca K Kpaio HaaropxaHHHKa. IlpH
HaaropxaHHHK, fleHcxsyex KaK pacmnpHxejib Exo^a H
ropxaHH BO BpeMa awxaHna H penn.
Ko II rpynne oxnocaxca «cyHCHBaxe:iH» FOJIOCOBOH mejin:
— m. cricoarythenoideus lateralis coe^HHaex SoKosyio nosepxHocxb nepcxxpama H MbimeHHHH oxpocxoK HepnajiOBH^Horo xpama. Dpn ee conpOHCXOflHX CMWKaHHC FOJIOCOBblX CKJiaflOK B nepeflHHX J(Byx XpCXHX,
ronocoBbie CKJia^KH npn 3XOM HeMHoro Hanpararoxca (pnc. 20);
— m. arythenoideus transversus pacnonaraexca Mexc^y sa^KHMH nosepxHOcxaMH HepnanoBHflHbix xpamen, coKpaiuaacb, cy>KHBaex roJiocoByio mejib B saaHCM oxflene.
O6e Mbiumbi oxHocaxca K ocHOBHbiM cy»(HBaxejiaM ronocoBOH meim. K MbimuaM — «noMOinHHKaM» cyjKHBaxeneH TOJIOCOBOH menn oxHocaxca m. m. arythenoidei oblqui, Koxopbie ne»cax csaflH nonepeHHOH HepnanoBHflHOH Mbiumbi.
K HI rpynne — «pacmHpHxejin» ro^ocoBOH meiiH — oxwocHxca m. cricoarythenoideus posterior seu posticus. Ona HanHHaexca Ha saflHefi noBepXHOcxH nepcxHCBHfl-
Jlbixanue
Puc. 20. CyaccHHe TOJIOCOBOH menu npw coKpameHHH napntix
m. cricoarythenoideus lateralis:
1 — m. cricoarythenoideus lateralis, 2 — cart, arythenoideus, 3 — lig. vocalis
. — m. thyreoarythenoideus nanHHaexca ox BHyxpeHHefi nosepxHocxH ruiacxHHOK inHXOBHaHoro xpama H npHKpenjiaexca K MwnieHHOMy oxpocxxy nepnajioBH^Horo xpanja. rtpn coKpameHHH paccna6jiaex ronocoBbie CKJia^KH;
— m. vocalis 3ano3KeHa B ronocoBOH CKJia^Ke. Ee BOJiOKHa H^yx B npoflojibHOM, nonepeHHOM H KOCOM HanpaBJieHHH, npn HX coKpameHHH Mbiuma HSMenaex
4>op\ry, Haxa»ceHHe H ynpyrocxb B qenoM.
IloJiocxb ropxaHH no 4>opivie nanoMHHaex necoHHbie nacw. Ilo KJiHHHKO-aHaxoMHHCCKHM npH3HaKaM ropxaHb pasflcnaiox na xpa ox^ejia. BepxHHH 3xa»c ropxaHH
orpaHHHCH csepxy BXOAOM B ropxaHb (cBo6o,HHbiH Kpaii jienecxKa HajjropxaHHHKa,
HepnanoHaAropxaHHbie cicnaflKH, sepxyuiKH lepnanoBH/uibix xpaiueft). B BCPXHHH
ox/ieii nojiocxH ropxaHH Bxo^ax BecxnGynapHtie (npejmBepm>ie, Jio^cnbie) rojiocoBbie
H ropxaHHbie xcenyzioHKH (yray6neHHe Me^yiy npe,zwBepHOH H FOJIOCOBOH
). B noflcnHSHCxOM cnoe acenyaoHKOB ropxaHH HMeroxca CKoruieHHa JIHM, BocnajieHHe Koxopofi HOCHX HasBaHHe «ropxaHHaa aHmHa».
3xaac ropxaHH cooxBexcxByex HCXHHHHM nxnocoBbiM CKJia^KaM,
KoxopbiMH o6pa3yexca roJiocoBaa ruejib.
3xa>K ropxaHH — noflronocoBoe npocxpaHCXBO — pacnojiaraexca
rojiocoBWMH CKJiaflKaMH H xpaxeeii. B nopMe npn nenpaMOH JiapHHrocKO3xox 3xa» ropxaHH Heo6o3pHM.
GiHSHCxaa o5ojiOHKa ropxanH aBJmexca npo^oiDKeHHeM CJIHSHCXOH TJIOXKH.
BepxHaa nacxb HajiropxaHHHKa, HCXKHHUC rojiocoBbie CKjiaflKH H Me^cuepnajiOBHaHoe npocxpancxBO y Aexefi BbicxnaHbi MHorocnoHHbiM ruiocKHM snHxeJiHCM, apyrae
oxflejibi — MHoropa^HbiM MepuaxenbHbiM snHxejiHCM. C BospacxoM ruiomaflb pacnpocxpaHCHHa MHorocjiOHHoro snnxejiHa yBejiH^HBaexca. B noflCJiHSHCxoH xKanH
HMeioxca cMemaHHbie ceposHo-cuHSHCXwe >Kejie3bi, B ocoGeHHOCxn — B cxeHKax >KejiyziomcoB ropxaHH, Koxopwe cnjoKax fljia yBJia>KHeHHa rojiocoBbix CKjia^oK.
Ha X3bimou noeepxHocmu nadzopmaHHUKa, cKJiadKax npeddeepun, e o6jiacmu Hepnanoeudnbix xpnufeu, e nodzonocoeoM
npocmpancmee nod cnusucmou naxodumcx CJIQU pbixnou KiiemHamw, mno odycnaenueaem ducmpoepassumue omem e 3mux
Mecmax npu eocr ^enuu, pasdpay/ceHuu UHOpodnbiM mejiom u
dpyzux npmunax. OmeK nodzojiocoeozo npocmpmcmea m
/pone ocmpozo eocnanenufi Hosbieaemcx «no3tcm>iu Kpyn».
a
96
TeMa VI. AHATOMO-OHSHOJIOri^MECKME OCOBEHHOCTH fOPTAHH
KpOBOCHa6»eHHe ropxann ocymecxBJiaexca BCXBJIMH BepxHeft IIIHXOBHUHOH
apxepHH (a. thyroidea superior) — aexBb napyacHOH COHHOH apxepHH H HHJKHCH
lUHxoBHflHOH apxepHH (a. thyroidea inferior) — BexBb mnxomefiHoro cxBona. BeHO3HWH OXXOK OCyUieCXBJiaeXCa HCpC3 CnjieXCHHa H OflHOHMCHHbie BCHbl BO BHyipCHHKDK) apCMHyiO B6Hy.
JlHM<J>axHHecKaa CHCxeMa ropxann COCXOHX H3 flByx OXACJIOB — BepxHen H
HH5KH6H rpynn, Koxopbie pasaeneHbi rojiocoBbiMH CKJiaaKaMH. OXXOK JiHM(J>bi B
SHaHHxejibHOH cxeneHH npe/ionpeflejiaex oco6eHHoexH pacnpocxpaneHHa onyxoJIH no npoxa>KeHHio H MexacxasnpOBaHHe. B HaacKnaaoHHOM oxaejie ropxann
HMeexca ABycjioHHaa cexb JiHM(J)axHHecKHX cocyaoB, XCCHO CBasaHnaa c cocyaaMH HMOK HaflropXaHHHKa, JlOflCa He6HbIX MHHflaJIHH, KOpHa a3bIKa, a XaK5KC C
BepxHefl H cpeaHHMH rpynnaMH JiHMcJmxHHecKHX ysjioB rjiy6oKOH apeMHOH HCHH.
JlHM(j)axHHCCKaa cncxeMa ronocoBbix cmiaflOK OXHOCHXCH K HHHCHCH co6cxB6HHOH HHM(|)aXHHeCKOH CHCXCM6 ropxaHH. Cexb JTHM^aXHHCCKHX COCy/lOB TOJIO-
coBbix cioiaflOK OHCHb CKyflHa, cocy^H pacnojioxceHbi npoaojibHO, npocsex HX
. Ox rojiocoBbix CKJia^oK HHM(J)axHHecKHe cocy^bi Bbixo^xx H nepes KOHHCBflSKy nanpaBiwioxca K npenapHHreajibHbiM JiHM(J)oy3JiaM. /Janee OXXOK
jiHM<J)bi npOHCxoflHX B cpc^HHe H HHHCHHC jiHM<j)oy3iibi my6oKOH apeMHOH uenw.
B CJIH3HCXOH oGoJiOHKe noflixuiocoBoro npocxpancxBa pacnonoaceHa MenKas cexb
HHM<J)axHHecKHx cocyAOB, Koxopwe 4)opMHpyioxc» B 6onee Kpynnyro cexb nepeaHHX H 3aflHe6oKOBbix cocyflOB. OXXOK jiHM(j)bi ox no/nxuiocoBoro npocxpancxBa
ocymecxBJwexca nepes npe^ropxaHHbie H
npe^xpaxeajibHbie JiHM(j)oy3Jibi B HHHCHIOK)
rpynny ysnos rny6oKOH apeMHOH qenH, a
xaicxce B JiHM^axHHecKHe ysnw Bepxnero cpeaocxeHHa (pnc. 21).
IlapacHMnaxHHecKaa HMHepBauna ropxaHH ocymecxBJiaexca flByMH BCXBSMH 6ny>KTiaromero nepsa — napnbiMH sepxHHM H
HH>KHHM ropX3HHbIMH HCpBaMH.
BepxHHH ropxaHHbiH nepB (n. laryn-geus
superior) OXXO^HX ox HHxcnero ysna
aaiomero nepsa H, He aoxoaa 30
HOH KOCXH, ^eJiHxca na ABC BCXBH: Hapyxcnyio
(r. externus), Koxopaa flBnaexca
Puc. 21. JlHM<J>aTHHecKaa
ropraHH:
1 — BepxHHH H cpe^Haa rpynnu JIHM(jjaTHHecKHX ysJiOB rjiySoKofl apeMHOH
uenH, 2 — HH>KHaa rpynna ;iHM<j>aTHnecKHx y3JioB rjiySoKofl apeMHOH uenH,
3 — naparpaxeajibHtie nHMCjiaTHHeCKHe
i, rjiySoKaa apeMHM Bena
HblM HepBOM H HHHepBHpyCX XOJIbKO
Mbiiuuy ropxaHH — m. cricothyroideus anterior, H BHyxpeHHioK) (r. internus), Koxopaa
ocymecxBJisex HyBCXBHxejibHyio HHHepBai(Hio
CJIH3HCXOH OGOJIO^KH TOpXaHH.
IlpaBblH H JlCBblH HH5KHH6 rOpXaHHblC H6p-
Bbi (n. laryngeus inferior, n. reccurrens) oxxo^ax
<t>M3nonornn ropxann. Meroflbi nccneflOBaHkia ropxaHM...
97
ox 6ny>KJiaK>mero Hepsa B rpyflHOH HOJIOCXH Ha pasnbix ypOBHax. IlpaBblH BOSBpaxHbiH Heps OXXO/IHX ox 6jry>KAaiomero nepsa na ypoBne ero nepeceqemia c HO/IKJIIOHHHHOH apxepneH, oni6aex ee CHH3y H noaHHMaexca nasepx K ropxann no 6OKOBOH
cxeHKe xpaxeH. JTeBbiH BO3BpaxHbiH Heps oxxoflHX ox 6jiy«cAaK)inero nepaa Ha ypoBHe sapameHHoro 6oxaiuioBa npoxoKa, oraSaex cnnsy /ryry aopxbi H B ^cenoGKe Mexcay
xpaxeeii H nnmeBoziOM noanHMaexca K ropxaHH. Ha CBOCM nyxH o6a BO3BpaxHbix
nepsa oxnaiox MHoacecxBennbie sexBH K xpaxee H nnmeBOfly. Tonorpa(J)Ha BO3BpaxHbix HepsoB o6ycjioBHHBaex jiBHraxeJibHbie HapyuieHHa ronocoBbrx CKnaaoK npn
C/iaBJlCHHH HCpBOB HpH HaXOJlOrHH B FpyflHOH HOJ1OCXH.
CHMnaxHiecKaa HHnepaaiiHa ropxaHH ocymecxBuaexcs HS Bepxnero uieHHOro cHMnaxHHecKoro (sBesanaxoro) cxBOJia.
II. <PM3MOJlOrM51 rOPTAHM. METOflbl MCCJlEflOBAHMfl
rOPTAHM. BBEflEHME B (DOHMATPMK)
(j)yHKijHH i opraim. PacmnpeHHe H cyxceHHe TOJIOCOBOH menn perynHpyex nocxynneHHe BO3flyxa B HHHCHHC flbixaxejibHbie nyxn. ITpn B^oxe
coKpamaexca sa/inaa nepcTHenepnajioEHflHaa Mbiuiua, pacuinpaiomaa rojiocoByio
b. Bo3flyuiHbiH HOXOK, nocxynaioruHH B ropxaHb, BsaHMOfleiicxByex c MHOTOpeuenxopaMH GnyayjaKimero nepBa B xojiiue CJIHSHCXOH o6onoHKH,
o6ecneHHBaa HepBHO-pe(})JieKxopHbie CBaan ropxaHH c ^pyrHMH opranaMH BepxHHX flbixaxejibHbix nyxeft H flbixaxejibHbiM uenxpOM opraHHSMa. TaKHM oGpasoM,
ropxaHb ynacxsyex B CJIOXCHOM MexannsMe xpancnopxa BflbixaeMoro H BbiflbixaeMOTO BO3^,yxa, oKasbisaex BJinaHHe na CKopocxfa H o6i>eM BOS^yiuHbix HOXOKOB
4»yHKUHH BKJiiOHaex B ce6a pe<j)JieKxopHyio Sammy HHXCHHX awxaxenbHbix nyxen ox nona^aHHa HHOpOflHbix xen, nnrnH, pasapaacaiomnx BCmecxB, a xaicace 6apbepHbie fyywai,HH CJIHSHCXOH 060:101101 ropxaHH.
Bo speMa npo^BHHceHHa nnmeBoro KOMKa HS FJIOXKH B nnmeBOA ropxaHb coBepuiaex flBH^ceHHe B nanpaBJieHHH cnnsy BBepx H csa/jn Bnepe^, npn 3XOM HepnanoHaflropxanHbie Mwuiubi coKpamaioxca, cy>KHBaa sxofl B ropxanb, a nenecxoK
HaflropxaHHHKa saKpbreaex Bxoa B ropxanb csepxy. CueflyrornHH pe<J)neKxopHbiH
SaiUHXHblH MCXaHHSM - KaillCJIb. ITpH paSflpaMCCHHH CJ1H3HCXOH OGOJIOHKH TOp-
xaHH MOKpoxoH, paaflpaacaiomHMH MeJiKO^HcnepCHbiMH »CHAKHMH HJiH ra3oo6BernecxsaiviH HJIH HHopo/iHbiM xenoM BO3HHKaex 4>opcHpOBaHHbiH npeBtwox, cnocoScxByiouiHH y^ajieHHio xsepflbix, »H^KHX H ra30o6pa3HWX nacxHu H3 ropxaHH. FIpH CHJibHOM pasapaaceHHH CHH3HCXOH ropxaHH HHOpoflHbiM xenoM, BpeanbiMH npHMecaMH BO BjibixaeMOM Bosflyxe BOSHHKaex pe<J»jieKxopHbifi cna3M ropxaHH — cyaopo)KHoe CMbiKaHHe ronocoBOH uienn, npenaxcxByiomee UPOHHKHOBCHHK) B HH^CHHC flbixaxejibHbie nyxn KaK pa3flpa»caioniero
arenxa, xaK H
98
TeMa VI. AHATOMO-<DH3HOnOrM^ECKME OCOEEHHOCTM rOPTAHH
BapbepHwe (pynKHHH CJIHSHCXOH oSojioHKH csassHH c MyicouHJiHapHbiM KJIHpencoM (nepsaa JIHHHH samnxw) H coScxseHHOH ruiacxHHKOH CJIHSHCXOH (Bxopaa
JIHHHa 33IHHXbl).
AKXHBHOcxb MyKOU,HJiHapHoro xpancnopxa saBHcnx ox cocxoaHna noicpbiBaiomero ero ceKpexa. FIpH CHHJKCHHH (npn ajuieprHH) HJIH noBbiuieHHH sasicocxH CCKpexa (npn KypeHHH), yMeHbiueHHH HJIH yBejinqenHH ero KOJiHHecrea cnnxpOHHOcxb
KOJieGaHHa pecHHHeK, no,ziBH>KHocxb noBepXHOCxHoro cjioa ceKpera Hapymaexca, H
cosflaioxca ycjioBHa #jia HapymeHHH roMeocxasa CJIHSHCXOH o6oJiOHKH H KOJIOHHsauHH B HCH 6aKxepHH. SamHXHbie CBOHCxsa ceKpera CJIHSHCXOH o6ojiotiKH csasaHbi
C paCXBOpeHHblMH B HCM (paKXOpaMH eCXeCXBCHHOH pCSHCXCHXHOCXH H CneUH(pHHe-
CKOFO HMMyHHxexa: jnoouHMa, KOMiuieMenxa, Jiaicro<peppHHa, nnxepipepoHOB, <parouHXHpyiomHx KJICXOK, pacxsopeHHbix HMMynorjioSyjiHHOB.
rojiocoo6pa3OBaTejii>Hasi <J>ynKunfl. CxpoeHHe ropxaHH nanoMHHaex cxpyicxypy a3biHKOBoro jryxoBoro MysbiicajibHoro HHcxpyMeHxa. HpHqeM fljiHiia, xojiujHHa, iiinpHHa rojiocoBbix cicnaflOK H cxeneHb HX HaxaaceHHa Moryx npoH3BOJibHO H3M6Haxbca. Ssyic oSpasyexca Ha Bbifloxe npn coMKHyxwx rojiocoBbix CKjiaaKax, npHHCM He Bos^yx KOJieSjiex cioiaflKH, a roJiocoBbie CKJiaJjKH Kone6axejibHbiMH ^BHaceHHaMH BtisbisaioT xonHKoo6pa3Hoe npo^BH>KeHHe Bos^yxa. Kojie6aHHH FOJIOCOBblX CKJiajtOK H3JJ3IOX 3ByK. OflHaKO, «CBa3OHHbIH» 3ByK 3H3HHXejIbHO
oxjiHiaexca ox ssyica ronoca, Koxopbift MM CJIWIIIHM. B 4>opMHpoBaHHH OKOHqaxejibHOH OKpacKH 3ByKa npHHHMarox ynacxHe see BepXHne jjbixaxejibHbie ixyxn
(pesonaxopHaa (pyHKUHa FJIOXKH, noca). OopMnposaHHe penn xaiOKe ocymecxBJMexca B BepxHHx flbixaxejibHwx nyxax 3a cnex apxHKyjiauHOHHbix flBH»ceHHH
ry6, Mareoro He6a, HHJKHCH ICJIWCXH, ropxaHH. KaayjOMy ssyKy cooxBercxByex
noJKmeHHe opraHOB sepxHHX awxaxejibHbix nyxen H poxoraoxKH.
roJiocooGpasyromero H apXHKyjiauHOHHoro annapaxa Haxoanxca
no/i peryjiHpyiomHM BjinaHneM noflKopKOBbix aflep H Kopbi roJiOBHoro Mosra.
OopMHpOBaHHe peHH HCBO3Mo»Ho 6e3 (pyHKijHH cjiyxoBoro aHajiHsaxopa, HTO
o6teaHHaex peqesyio H cjiyxoByio (pynKqHio B e^HHyio «Bxopyio cnrHanbHyio
CHCTCMy» BblCmCH HCpBHOH ^eaXCJIbHOCXH.
Meroflbi MCcneflOBaHMfi ropraHM
HccneaoBaHHC ropxaHH Hainnaexca c ocMoxpa H ^a)Ib^a^HH o6jiacxn ropxaHH, nepe^Hefi H GOKOBHX noBepxHocxefi men, naa- H noAKJiiOHHHHbix aMOK. Cjie^yex nposepHXb CHMHXOM ropxaHHOH icpeiiHxauHH (CHMHXOM Mypa), nocKOJitKy
oxcyxcxBHe omymeHHa KpennxauHH npn nepe^BH>KeHHH ropxaHH B ropnsoHxanbHOM HanpaBJieHHH aBjiaexca npnsHaicoM onyxojin.
HenpHMaH .lapmirocKonna ^jia Hccjie^OBaHHa ropxaHH aspocjibix ncnojibsyexca Han6oJiee mnpoKO. V jjexeft cxapuiero Bospacxa npoBcaenne Hccjie^OBaHHa xexHHnecKH He oxjinnaexca ox HccneflOBaHHa B3pocJibix. V jjexefi MJia^uie 7H jiex He Bcerjja yaaexca nposecxH HenpaMyro JiapHHrocKonnio H3-33 cxpaxa pe-
ll. OM3MOjiorna ropraHM. Mexoflbi MccnefloeaHna ropxaHM...
nepe^ BpanoM, o6njibHoro cjiioHoox/iejieHHa, oxnasa BbicyHyxb aswK. B
xaKHX cjiynaax uinaxejieM oxxarHBajox Kopenb asuKa KnepeflH H KHH3y, nocjie
qero najjropxaHHHK nojjHHMaexca H oxKpbmaeT BX.OR B ropxanb. 3epKano ycxaHaBJIHBaiOX K3K MOKHO HHXC K Sa^HCH CXCHK6 FJIOXKH. EcJIH BOSHHKaeX cna3M
BHyxpeHHHX MWHIU ropxaHH, sepKajio ne cjiejjyex ySnpaxb, xaK Kan 33 cnasMOM
nocjieayex ray6oKHH Bflox, HXO OOSBOJIMX ocinoxpexb ropxanb.
IIpflMan jiapHHrocKonna asnaexca e/(HHCXBeHHbiM cnoco6oM ocMoxpa ropxaHH y rpy^Hbix aexefi H JJCTCH MJiaauiero sospacxa. 3xox MCXOA
npHMenaexca xaK5Ke fljia npose^eHHa GHOHCHH, yaajieHH
HOBOo6pa30BaHHH ropxaHH. IlpaMaa jiapHnrocKonHa ocHOBana Ha MexaHHiecKOM
yrna MetKpy ocbio poxoBOH OOJIOCXH H ocbio ropxaHH. /Jjia npoBeHccjieflOBaHHa xpe6yexca cneunajibHbiH uinaxejib C. A. TnxoMHpoBa HJIH
yHHBepcanbHbiH jjHpeicxocKon B. O. YHflpHiia.
TexHHKa npoBe^eHHa: pe6enoK Haxoanxca B HOJIOXCCKHH jie>Ka na cnnne, noa
ero OJICHH no^KJiaflbiBaexca neSojibiuoH BanHK HJIH pyKa accncxenxa. FojioBa peSeHKa sanpOKH^biBaexca y Kpaa cxojia xaKHM oSpasoM, nxo6w nofl6opoaoK, nepejjnaa nosepxHocxb men H rpyflH Haxo^HJiHCb na O^HOH npaMOH. Bpan BBO^HX
uinaxejib B rnoxicy JICBOH pyKOH, CKOJitsa ero KOHUOM no cnHHKe asbiKa. JleneCXOK HaflropxaHHHKa oxrecHaexca Knepe^H, OCMaxpHBaexca nojiocxb ropxaHH.
MHKpojiapHHrocKonHH — HccjieflOBaHHe ropxaHH c noMombio XHpypraraecKOro MHKpocKona c (poKycHbiM paccxoaHHCM 300-400 MM, Koxopoe MO«HO nposoflnxb
K3K npn npaMOH, xaK H npn HenpaMOH jiapHHrocKOHHH. IlpaMaa MHKpojiapHHrocKOnna npoBOAHXca no^i o6meH aHecxesneH, HenpaMaa — HOA MCCXHBIM o6e36oJiHBaHHCM. Ha OCHOBC MHKpoJiapHHrocKonHH pasBHsaexca MHKpoxHpypraa ropxaHH.
JlapHHrocrpoSocKonHH. Ha6jiioflaxb sa 6bicxpbiMHflBHKCHHaMHrojiocoBbix
CKJiaflOK C nOMOin,bK> oGblHHHX MCXOZIHK JiapHHFOCKOnHH HCBO3M05KHO, HOCKOJIbKy
nacxoxa flBH^ceHHH MO>Kex flocxHraxb 6ojiee 2000 flBOHHbix KOJie6aHHH B 1 ceicyHjsy. BocnpHHHMaxb Gbicxpwe flBHjKCHHa rojiocoBbix cioiaflOK nosBOJiaex 4>H3HKOonxHHecKHH cnocoS Ha6jiK>fleHHa -— cxpoGocKonna. OcMoxp ropxaHH B npepwBHCXOM CBexe (jiapHHrocxpoGocKonna) nosBOJiaex BHaexb oxaejibHbie KOJie6aHH« rojiocoBbix CKJia^OK. HanSoJiee nacxo 3xox MCXO/I HCCJie^oBaHHa ncnojibsyexca B (poHHaipHH. IIpH CXpoSoCKOIIHH o6pam3K)X BHHMaHHC H3 HanpaBJICHHC KOJie6aHHH
rojiocoBbix CKJia^oK, aMiumxy/iy H CKOpocxb KOJieSanHH. OnncaHbi cxpo6ocKonnqecKHe KapxHHbi, xapaxxepHbie ^Jia pasuHHHWX 3a6ojieBaHHH ropxaHH.
3jieiapOMHorpa4)HH ropraHH — HCCJieaoaaHHe 6HO3JieKXpHqecKofi axxHBHOCXH napyxcHbix H BHyxpeHHHX Mbiuiu ropxaHH. 3xox Mexoa HCCJieaoBaHHa aBjiaexca H3H6ojiee yaoOnbiM ana OCHOBHOTO HCCJieflOBaHHa 6HO3JieKxpHHecKOH 3KXHBHOCXH CHCX6MH HHHCpBSUHH TOpXaHH. HcCJIC^OBaHHe HOSBOJiaCX ^HarHOCXH-
posaxb (pyH^HOHajibHbie paccxpoiicxBa roJiocoBoro annapaxa y JIHU peneflbix
npo<peccHH, a xaiOKe panHHe cxazjHH paica ropxaHH.
HctneflOBaHHe (pyHKUHH BHeuiiiero Abixannn nossojiaex onpejiejinxb ynacxoK
oScxpyKUHH flbixaxeJibHbix nyxen, BbisbisaiomHH ^bixaxejibHyio He^ocxaxoHHOcxb.
100
TeMa VI. AHATOMO-OHSklOJIOrMHECKME OCO5EHHOCTH TOPTAHH
PeHTreHOJiorHMCCKHe MeTO,ni>i HccJieflOBaHHH — peHxreHorpa<j)Ha H XOMOrpac})Ha ropxaHH B nepe^He-saaHeH H GOKOBOH npoeKiinax — noSBOJiaiox nojiyHHXb CHHMKH FOpXaHH, npH H3yHCHHH KOXOpblX MO5KHO OUpeflejIHXb COCXOHHH6
BCCX ox^enoB ropxaHH H uieHHoro oxaeira xpaxen.
opraHOB rojiocoo6pa3OBaHMfl
oxopHHonapHHronorHH, oGjiacxbio HHxepecoB KOXOpoK aBjiaioxca Mexoflbi <J)OHexHHecKoro HccneflOBaHHa H jieneHHa paccxponcxB
peHH H rojioca. B oSnacxb HHxepecoB (J)OHHaxpHH EXO^HX nocxanoBKa neBHecicoro, KOMaHflHoro rojioca, JieneHHe <})yHKUHOHajibHbix paccxponcxB rojioca, <J)OHejieneHHe jiapHHrsKxoMHpoBaHHbix 6o;ibHbix, JieneHHe saHKaHHa peneynpawHCHHaMH, JieneHHe KOCHoasHHHa H pHHonajiHH.
ITpaBHJibHaa penb o6pa3yexca npn KoopjjHHHpoBaHHOH aeaxenbHOCXH xpex
6ojibuiHX MbimeHHbix rpynn: AbixaxejibHOH Mycxyjiaxypbi, TOJIOCOBOH H apxnicyjiau,HOHHOH MycKynaxypbi.
/],bi xaime npH aicre (J)onauHH. /JwxaHHe JIOKHX B OCHOBC HCHSHH. Eme B
flpeBHOCXH noHaxna «^bixaHHe», «Ayx», «BfloxHOBCHHe», «flyxoBHHH» GHJIH
XCCHO BsaHMOCBasaHbi. O6meH3BecxHO, HXO aMnnnxyaa H PHXM flbrxaHHa MBHHlOXCa B 3aBHCHMOCXH OX flyUICBHOrO COCXOaHHH (KpHK, CMCX, SCBaHHC H X. fl.).
OCHOBHHM MaxepnajioM, cosaaiomHM 3ByKOByio 3HeprHio B ropxaHH, asjiaerca
B03^yx. Ilpn rojiocooSpasoBaHHH BO3^yx flocxasjiaexca jierKHMH BO BpeMa cfiasbi
Bbmoxa B ropxaub, r^e H npoHcxo^nx cro osByHHBaHHe. /JbixaxeJibnaa eMKOcxb
jierKHx saBHCHx ox Bospacxa, xejiocno^eHHa H BHCOXW xena, nojia, o6mero 4>H3HqecKoro pasBHXHH, B cpeaneM flocxnraa CBOero MaKCHMajibHoro pasBHxna K 35-H
rojaM. y ycHJieHHO ynpaxcHHiomHxca neaqoB MaKCHManbHaa abixaxenbHaa eMKocxb Ha6jiKmaexca B Bospacxe 50-55 nex. flbixaHne peryjinpyexca flbixaxenbHbiM
uenxpOM npoflonroBaxoro Mosra, Koxopbin nocbinaex ^BHraxeJibHbie HMnyjibcw KO
BCCM flbixaxenbHHM MbimqaM H MycKynaxype 6pOHXOB. FjiaBHbiM
AbixaxejibHoro qenxpa asnaexca cojiepxcaHHe flsyoKHCH yraepo^a B KpoBH.
HCManoBaHCHa H pe<JwieKxopHaa perynauHa ^wxanna no^ BOSfleHCXBHCM caMbix
pa3Hoo6pa3Hbix cxHMynoB, BKnioqaa xaicace ncHXHHCCKHe pa3^pa>KHxejiH. Ox BCCX
HHblX (J)yHKLlHH OpraHH3M3 flblXaHHC OXJIHHaCXCa LUHpOKHM ^YHKUHOHajIbHblM
^HanasoHOM, peryjiauHH Koxoporo ocymecxBjiaexca Ha noflcosHaxenbHOM yposne H
npOH3BOJibHO. 3xa oco6eHHOcxb apKO npoaBJiaexca B npoH3BOJibHOM abixannn, nrpaiomeM Ba»Hyio pojib BflHiJj^epeHUHpoBaHHOMrojiocoo6pa3OBaHHH.
Me)Kfly flwxaHHCM B cnoKOHHOM COCXOHHHH H flbixaHHCM BO BpeMa penn cymecxByex oipoMHaa pa3HHqa. B cocxoaHHH noKoa cooxHomeHHe Bfloxa H Bbi^oxa
cocxasnaex npHMepno 3 : 4. Bo BpeMa peHH BAOX oxHocnxenbHO KOpoxoK, a BHaox yaJiHHCH. IIpH npOHSHeceHHH anHHHbix <f>pa3 Bbi^ox MO»ex npesocxoanxb
no ^JiHxejibHocxH B«OX B 8-12pa3. O,zniH HS ceKpexoB xopouiero neHHa H opaxopcKOH peHH Kpoexca B yMCHHH 3KOHOMHO pacxoflOBaxb Haxo/iamHHca B JICFKHX
II. <t>M3Monorna ropraHH. Mexoflbi nccneflOBaHnsi ropraHM..._
101
. KaK npaanjio, BO BpeMa penn B^OX nponcxoflHX nepes pox. Flpn nopManbHOM BAOXC BO BpeMa penn aswK nnocKo ne»Hx BO pxy, ronocoBbie cKnaaKH
uiHpOKO pacxo/iaxca. B 3XHX ycnoBHax BAOX KHXCHCHBHWH, KOpoxKHH, HO coBepmeHHO 6e33BynHbiH. ECJIH HMCCXCH npenaxcxBne xoKy sosayxa BO BpeMa peHH, na Bfloxe noaBjiaexca uiyM, HOXO>KHH na 3ByK «x». Bbiaox BO BPBMH penn yaJIHHCH, a xapaKxep Bbifloxa — nepaBHOMepHbiH, co MHOFHMH nepepwBaMH B coOXBCXCXBHH co CMbicjiOM peHH. HanpHMep, cxeMaxHHecKH Bbmox BO BpeMa npoHsneceHHa 4>pa3bi «OflHa>KAbi, ne6e/jb, pan aa myKa, BCSXH c noKJia>KeH BOS B3anncfa» MOJKHO H3o6pa3HXb cne^yiomHM o6pa3OM:
B^ox
BblflOX
Cxpya Bosayxa npepbiBaexca xaM, rae sanaxbiMH yKasano npepbiBanne MMCJIH.
IlpH HopManbHOH peiH o6teM Bos^yxa, HaKOHJieHHWH B nencHX BO BpeMa
pacxoayexca SKOHOMHO, xo ecxb BO BpeMa «npepbiBaHHa MbicnH» Bosjjyx
xejibHO He Bbmwxaexca, HOBbie B^OXH He npoHSBO^arca. ECJIH npn npoHSHomeHHH
4>pa3 HMeioxca nacxbie npoMe^cyxoHHbie HHcnnpauHH, opaxopcKaa peib HanocHX
rojiocoBbiM CKJiaflKaM (cnocoScxByex cyxocxn CJIHSHCXOH), BOSHHKaex noKame, a xopouiee nenne npocxo HCBOSMOJKHO. XopouiHH opaxop HJIH neBCij aoji>KCH nyxeM ynpa)KHeHHH naynnxbca peryjinposaxb MycKyjibHyio paSoxy xaKHM o6pa3OM, HXO6bI BblflOX npOHSBO^HJICa K3K MO)KHO Me&IteHHee H 3KOHOMH6e.
B noKoe <j)H3HOJiorHHHbiM aBJiaexca awxaHHe nepes HOC. Bo BpeMa penn, neHHa cxpyn Bos^yxa na B^oxe H Bbi/joxe npoxo^HX npeHMymecxBCHHO nepes IIIHPOKO pacKpwxblH pox (sa HCKJHOHCHHeM nays BO BpeMa penn H nenna, Kor^a opaxop HJIH neseu ox^bixaex H MOJIHHX). Hcxo^a H3 (j)H3HOJiorHH ^bixaHHa BO BpeMfl
peHH, opaxopaM H nesuaM MOHCHO ziaxb peKOMeHflauHKi: He pasroBapHBaxb H HC
neXb B CJIHIUKOM XOJIOflHOM, HblJIbHOM H CJ1HUIKOM CyXOM nOMemCHHH.
<PH3HOJiorHH (J)oiiaunn. Ilpoqecc rojiocooGpasoBaHHH BW3biBaji nnxepec
C flpCBHHX BpeMBH. Eme
BO BpCMCHa THnHOKpaxa 6bIJIO H3BCCXHO, HXO FOJIOC
BO3HHKacx B ropxaHH. O/iHaKO jiHinb 20 BCKOB cnycxa B 1593 r. AHAPCH BeBbiCKaswBaex MHenne, HXO ronoc npoayuHpyexcH ronocoBbiMH cKjia^. Hanajio 6ojiee CHCxeMaxHSHpoaaHHbix HCCJieAOBaHHH 4)OHauHH OXHOCHXca K XVIII B. IlocKOJibKy B xo BpeMfl cymecxBOBajia xeHflCHuna o6i.acHaxb
4)yHKUHH HeJiOBenecKoro opraHHSMa (^HSHHCCKHMH npoueccaMH,
JIH XOH snoxH npeflcxaBJiajiH ce6e rojiocoBbie CKJiaaKH Hanoflo6HC cxpyn
KajibHoro HHCxpyMCHxa H aaiiH HM HassaHHe «rojiocoBbie cxpyHbi». DosAHee, B
pesyjibxaxe naKonjieHHbix Ha6jnofleHHH, BOSHHK paa «nepH(J)epHHecKHX» xeo-
102
TeMa VI. AHATOMO-<frM3HQj1OrMMECKME OCO5EHHOCTH rOPTAHM
PHH rojiocoo6pa3OBaHHa, OCHOBHBIMH H3 Koxopwx GUJIH MHosjiacxHHecKaa H
npoxHBonojio)KHaa efi HCHpoxpoHaKCHHecKaa xeopHH.
CoraacHo MHO3JiacxHHecKOH xeopHH, BbiABHHyxoH Ferrein B 1741 r.,
una — pesyjibxax BH6pau.HOHHbix aBHaceHHH TOJIOCOEWX CKJia/jOK B
HOM nanpaBJieHHH noff. BosjjeHCXBHeM Bos/iyiiiHOH cxpyn BO BpeMa BbiAoxa. TJiia
peajIH3au,HH BHGpaUHOHHHX aBroKCHHH c6jIH>KeHHfl H yuajICHHH FOJIOCOBblX CKJI3-
ZIOK Heo6xoaHMO nanHHHe .uayx npoxHBonojio>KHbix CHJI: CHJIW flaBJieHHa BbiabixaeMoro sos^yxa H CHJIH npHBe^eHHa ronocoBbix CKjiaAOK B 4>OHaxopHoe nojio>KeHHe, oSecneHHBaeMOH BCCMH BHyxpeHHHMH MbimuaMH ropxaHH. /J
B03AyiiiHOH cxpyn o6ecnenHBaex pacxo:»yieHHe FOJIOCOBHX cioia^oK H
5KHBaexca BCCH flbixaxejibHOH MycKyjiaxypoH, ynacxByromeH B ifiase
BnyxpeHHHe Mbiniubi ropxann nepesoAax ronocoBbie CKJia^KH B cocxoaHHe aaflyKLJHH, OKaSblBaa COnpOTHBUCHHe BO3flyiUHOH CXpye. B OCymCCXBJieHHH (j)OHa-
xopHOH <J)yHKL(HH lenoBCKa npHHHMarox ynacxHe 40 ox^eJibHbix Mbiiim — nuxaxejitHbix, jiapHHreanbHwx H apxHKyjmijHOHHbix.
HeHpoxponaKCHHecKaa xeopna (J)OHaaHH BbiflBHHyra B 1950r. 4>paHuy3CKHM
HCCJieflOBaxeneM — (JJHSHKOM, MaxeMaxHKOM, MCAHKOM H neBuoM — R. Husson. C
MOMCHxa CBoero noHBJieHna xeopna HMeex MHTOKCCXBO IIPOXHBHHKOB, oanaKO ee
BlOiafl B pa3BHXH6 HCCJlC^OBaHHa (])H3HOJIOrHH rOJIOCOo6pa3OBaHHH OrpOMBH. CO-
raacHO 3XOH xeopHH, BnOpaiiHfl ronocoBbix CKJiauoK npeAcxaBiwex coGon aKXHBHblC flBTOKeHHH FOJIOCOBblX MbllllU, npOHCXOflHUIHe nOfl /jeHCXBHCM BO3HHKaK)mHX B
uenxpajTbHOH HepBHOH CHCxeMe H nocxynaromHX no BOsspaxHbiM HepBaM HinnyjibCOB. R. Husson cnnxaji, HXO oxKpbiXHe ronocoBOH mejiH — HC naccHBHoe
HHC, a aKXHBHbifi oxBcx Ha £BHraxenbHWH HMnyjibC. 3aKpbixne ronocoBOH
Hao6opox, — naccHBHaa (J)a3a, saBHcamaa ox 3JiacxHHHOcxH TOJIOCOBBIX
BosflyiJiHaH cxpya, oGpasyromaacH BO speMx Bbi^oxa, HBJiHexca He flBH^cymeH CHJIOH KOJie6axejibHbix «BH>KeHHH rojiocoBbix CKnaaoK, a BemecxsoM, HS Koxoporo
rcHepHpyexca SHeprna — 3ByK. ^acxoxa 3ByKa, renepHpyeMoro B ropxaHH,
OX BO36y/lHMOCXH BOSBpaXHblX HepBOB, X. 6. OX HX CnOCo6HOCXH npOBOflHXb
HHH HMnyjibC. CoraacHo axofi xeopHH, sapOKjjeHHe <j)OHaxopHbix nepBHbix HMnyjibcoB npoHcxo/iHx Ha xpex ypoBHHX uenxpajibHOH HepBHoii CHCXCMH: Kopxn, flH3Hue(})anbHOM H 6yjib6apnoM, Ka5KjjbiH HS Koxopwx HMeex co6cxBCH«nacxoxy pHXMa» H pecJwieicxopHbie CBHSH. TaK, nenne HJIH pasroBopHWH rojioc, ycxaHOBJieHHHH na >KejiaeMOH Bbicoxe, oGecneHHBaexca reHepauHeii nepBHbix
HMnyjibcoB KopxHKanbHOH flBHraxe^bHOH soHbi. OsByHHBaHHe o6biHHOH pasroBOpHOH peiH 6e3 cosHaxenbHoro onpeflejieHHa xonajibHOCXH ocyiuecxBJiaexca HMnyjibcaMH aH3Hqe(j)ajibHoro ypOBna. Ha 6yjib6apHOM ypoBHe renepHpyroxcH (JjonaxopHbie HMnyjibcw B HCKOxopbix cneuH(J)HHecKHX ycuoBHax (pe^JieKxopHWH KpHK,
(j)OHauHa B COCX03HHH HapKO3a, MOHOxoHHoe HxeHHe HeHHxepecHoro xeKcxa).
3aciiy>KHBaex BHHMaHHH xafOKe MyKOOH^yjwxopHaa xeopna J. Perello (1962 r.).
O6meH3BecxHO, HXO no#cjiH3HCXbiH CJIOH rojiocoBbix CKJiaflOK HMeex pbouiyio
cxpyKxypy, HXO oco6enHO apKO npomnaexcH npn naxojiorHnecKHX COCXO»HHHX
d>M3MOJiornfl ropxaHH. Mexoflbi nccneflOBaHna ropraHH...
103
oxeHHoro xapaKxepa — OXCK PCHHKC, KBHHKC HJIH ocxpuft JiapHHFHT. HSBCCXHO
xaioKe, HXO cyxocxb CJIHSHCXOH OOOJIOHKH TOJIOCOBHX CKJia^OK conpoBO>Kaaexca
flHC(})OHHeH. Ha ocHOBaHHH cxpo6ocKonHHecKHx HCCJieaoBaHHH asxop npnuieji K
BbiBOfly, HXO HaSjiioaaeMaH BnOpaiiHa FOJIOCOBOH CKJia^KH ecxb ne HXO HHOC, KaK
CBoeoGpaaHoe BOJiHooGpasnoe cKOJib>KeHHe CJIHSHCXOH oGojioHKH, noKpHBajomen
rojiocoBbie CKJiajjKH. 3xo BonHOo6pa3Hoe /(BH^KeHHe naHHHaexca B cy6xopj;aj]bHOH
o6jiacxH, pacnpocxpaHflexca KBepxy H cnepe^H naaaa, npoxo^nx no Kparo FOJIOCOBbix CKJiaflOK, npoaojixaexca na BepxHen nosepxHOCXH rojiocoBbix CKjiaflOK H racHCX y Bxo/ja B ropxannbiH HcejiyfloneK. Do SXOH xeopHH JiapHHreanbHbie Mbimubi
xaK5Ke ynacxByiOT B HSMCHCHHH xojimHHbi H 4>opMbi rojiocoBbix CKJia^oK.
<t>n ino.iornn apTHKyjifliiHOHHbix /iBir/KCHHH. OH3HonorHHecKaH pojib apBH5KeHHH
o6pa30B3HHe HJieHOpa3fleJlbHHX 3ByKOB, KaK BO
penn, xaK H npH neHHH.
B HJienopasaejibHOH penn Bbiflejiaiox rjiacnbie H corjiacnbie ssyKH. Opn npoH3HOUICHHH TJiaCHOFO 3ByK3 H6T npHMCCH KaKHX-JlH6o UiyMOB, npOH3HOU16HHe
«3ByHHoe». HsMCHCHHe SByHHOcxH rjiacHbix npOHCxo^HX npn HSMenenHH <})opMbi
xpy6KH Haa rojiocoBbiMH cicnaaKaMH: H3MeH6HHe nojiWKeHHJi ry6,
a. K oGpasyioiueMycH B ropxaHH ssyKy npn SXOM npHMeniHBaioxca onpe^eoSepxoHw. HanpHMep, npH COOKOHHOM npoHSHomeHHH ssyKa «y» rySu
BbixarHBaioxca snepea, a ropxaHb onycKaexca KHHsy, XEKHM oGpasoM, flbixaxejibnaa xpy6Ka HMCCX HaH6ojibiuyjo AJiHHy. HpH npoHSHonieHHH «H», ry6w oxxarnBaroxca nasa^, a ropxaHb necKOJibKO npnnoaHHMaexca, H awxaxejibnaa xpy6Ka
yKOpanHBaexca. ECJIH BO apeMH npOHsnoiiieHHa 3ByKa noHBJiaexca uiyM xpenna
HJIH BSpwBa BCJICACXBHC MexaHHHecKoro npenaxcxBHa xoKy Bos^yxa nepes pox —
3ByK couiacHbiH. Ox/jejibHbie corjiacHbie 3ByKH penn oSpasyioTca B xpex Mecxax
«apxHKyjiaL(HOHHOH» xpy6KH:
— na Kparo ry6 (6, n, B, $, M, aexcKoe p);
Ha KOHHHK6 »3bIKa (ft X, 3, C, >K, UI, th
aHFJI., I
H6M., aHFJI. H DOJlbCK., H);
— Ha cnHHKe aswKa (r, K, x, H, ji — pyccKoe, r — anrji., ng — aHFJi.)ApxHKyjiauHOHHbie ^BHKeHHa MUIIIU He6HOH sanaBecKH, ^Ha HOJIOCXH pxa H
a, HH5KH6H HCJIIOCXH npH npOH3HeceiiHH Ka5Kaoro ssyKa xpaHC(j)opMHpyK)x
nyxn Bbiiiie rojiocoBbix cioiaflOK B ocoSyio (JiopMy. Ilpn SXOM cnjia
coKpameHHa Ka>tmoH H3 MbiiueHHbix rpynn oxjinnaexca npH npoH3HOuieHHH paaHWX SByKOB. HanpHMep, CHJia coKpamenna He6HOH saHasecKH (xo ecxb CHJia ee
npH»HMaHHa K sa^HCH CXCHKC FJIOXKH) npn npOH3HomeHHH ssyKa «a» npaKXHHeCKH B aBa pasa MCHbiue, HCM npn npoHSHOiueHHH ssyKa «c». Opn npoHSHOineHHH
«HOCOBHX 3ByKOB» noxoK Bosziyxa ynnpaexca B saxBop B HOJIOCXH pxa H yxo^HX
nepes oxKpwxyro He6nyro sanaBecKy B nojiocxb noca (ssyKH — M, H, ng).
OoHHarpHHecKoe oScjicaoBanHe Sojibnoro c naxojiorHen rojioca — npouecc, xpeSyromHH CKpynyjiesHoro noflxoAa H ox Bpana, H ox nanneHxa. HOMHMO
Ha6opa HHCxpyMCHXOB jyix oxopHHOJiapHHFOJiorHHecKoro o6cjieflOBaHHa coBpeKaSnHex (J)OHHaxpa ocnameH annapaxypoii /tna (j)OHHaxpHHecKoro HC-
104
Teiwa VI. AHATOMO-<DM3MOnOrHMECKHE OCOBEHHOCTI/I TOPTAHM
cxpo6ocKonoM, 3neKTpornoTTorpa(j)OM, cnHporpa(J>oM,
HJIH (J)HC1 apMOHHBH C TpeMH OKTaBaMH, COHaipa^OM, MarHHTO(})OHOM, XOHOHaCTOTHBIM aHajIH3aTOpOM, IliyMOMCpOM.
O6teKTHBHoe Hccne^oBaHHe HaHHHaexca c oxopHHonapHHronorHHecKoro
o6cjiejioBaHHa. IlpH (J)OHHaxpHHecKOM Hccne^oBanHH oqeHHBaioxca cne^yiomHe
noKaaaxejM: XOHOBWH ^Hanaaon neBnecKoro rcmoca; xeMSp H CHJia nwioca; axaKa
H npoflOJi*HxejibHocxb xona ronoca; cxpo6ocKonna ropxaHH, oijeHKa
4>yHKUHH MflrKoro He6a. HHoraa xpe6yexc» ncHxoHeBpojiorHnecKo
e, anjieprojiorHHecKoe o6cne^oBaHHe, HCCne^oBaHHe cnyxa.
Bonpocbi ana uxoroeoro KOHrponn 3H3HMM no xewe VI
1 . KaKne aHaxoMMHecKne o6pa3oeaHMfl cocxaenflioT BecTn6y/iflpHbiM
ropxaHH?
2. B K3KOM oxflene ropxaHM Han6onee paaenxbi KnexnaxoHHbie npocxpancTBa n Bbipa>KeHa oxsoflamaa nHMcfjaxuMecKaFi cexb?
nMxe Hapy>KHbie MbiLuqbi ropxaHM.
KaKne rpynnbi flennxcn BHyxpeHHue Mbiujuibi ropxaHH?
5. KaKoii neps nopa>KeH, ecru oflHa no^oBMHa ropiaHM HenoflBMKHa
npM flblXaHUM M (jlOHaMMM?
6. JlepeMMCJiMxe pecfaneKCoreHNbie 3OHbi ropxaHM.
t KaKne apxepMM o6ecneHMBaiox KpoBOCHa6>KeHMe ropxaHM?
noMombio KaKoro MncxpyivieHxa Bbinonnfltox npaMyio napMHroCKOHMIO?
9. KaKafi anecxesMH Mcno/ibayexcn B flexcKOM eospacxe flnji npose10. KaKMe >Kano6bi BOSHMKH/X npM aaSonesaHMHX ropxann?
flonofiHumefibHo dnn neduampimecKOZo (paKynbmema:
1 1 . KaKOBbi anaxoMMHecKMe oco6eHnocxM ropxaHM aexeM pannero BOSpacxa?
12. HeM oScynoeneHO B03HMKHOB6Hne Bpo>KfleHHoro cxpMflopa ropxaHM?
13. B KaKOM BoapacxHOM nepMOfle Ha6nioflaexcfl ronocosafl
14. Mxo oananaex xepMMH «no>KHbiM Kpyn»?
VII.
SAEOJlEBAHMfl HOCA
M OKOnOHOCOBblX HA3YX
Bpeun saHHXnn — 180 MMH/X.
Uenb aaHnTMH. MsynMXb KnMHMKy, flnamocxMKy M
neneHMe 3a6oneBaHMM nonocxM M npMflaxoHHbix nasyx
Hoca, pMHoreHHbix BHyxpMOp6MxanbHbix M BHyxpMMepenHblX OCJIOKHeHMM.
1. Pa3o6paxb xnnnHHyra KriMHMHecKyio Kapxuny sanoca M oKononocoBbix nasyx.
2. OanaKOMMXbCfl c coBpeivieHHbiMM MexoflaMM ne3a6o/ieBaHMM noca M npMflaxoHHbix nasyx Hoca.
3. Paso6paxb noKasanun, xexnMKy Bbino/iHeHMfl XMpyprnMecKMx BwemaxenbcxB B HOJIOCXM noca M npMflaxoMHbix nasyxax noca.
4. Pa3o6paxb ocnoBHbie nyxM npOHMKHOBeHM^ MHB rnasHMLiy, nonocxb sepena.
5. Paso6paxb KnMHMKy, flMamocxnKy M npMHUMnbi
punorenHbix BHyxpMop6nxa/ibHbix v\6. OsHaKOMMXbCJi c cospeMeHHbiMM
CKMMM npenapaxaMM flnn neneHMa 3a6oneBaHMM Hoca M
era npMflaxoMHbix nasyx.
flonofiHume/ibHO dnn neduampuvecKoao
7. OsHaKOMMXbcs? c oco6eHHOcxnMM
M jieHeHMH flexeM c naxonorMeM Hoca M npMflaxoMHbix
nasyx Hoca.
(fiaKyribmema:
6. Paso6paxb oco6eHHOcxn xeneHiia CMHycuxoe oflOHxoreHHoro renesa.
OcHau46HMe. OcBexMxenbHbie npM6opbi: MCXOHHMK
csexa, no6HbiM pecpneiuop, OXOCKOP, napMHrocKon, BOJ1OKOHH351 OnXMKa.
106
Teivia VII. 3AEOJlEBAHMflHOCA H OKOJIOHOCOBblX HA3VX
Ha6op MHcxpyweHxoB. Hocoebie aepKana, ninaTenn, yuiHbie eopoHKM, ropTanHbie M HOCornoTOHHbie sepKana, aoHflbi HaBMBHbie, nMHMeTbi yiiiHbie, nHHqerbi
HOCOBbie.
Pa6oMee wecxo. HHCTpyivieHTanbHbiii CTOJIMK, HacronbHaa nan/ina, cnnproBKa, flsa cryiia.
fleMOHCTpaquoHHbiH Marepna/i. PeHTreHorpaMMbi, orpa^atomne naionornio Hoca M npHflaroHHbix naayx Hoca.
Mecjo nposefleHMfl samrnm. VMe6Hap KOMnaxa, OTfleneHkie OTOpMHonapHHjiMTeparypa:
1. Condamoe M. B. JleKiinn no OTopuHonapuHronornn. — M.:
1990.
2. OemiHHUKoe K). M. OxopMHOJiapMHronorMfl. — M.: MeAnqnHa, 1995.
3. LUeepb&uH 5. B. PyroBOflcxBo no flexcKOM OTOpnHonapnHronornn. — M.:
, 1985.
I. 3AEOJlEBAHMfl HAPVOKHOfO HOCA
I. 3a6oneBaHMfl Hapy>KHoro Hoca
107
ry6w, ycHJieHHCM ceKpeimn cartbHbix H noxoBbix scenes,
pHHHHMH OCo6eHHOCXaMH OpraHHSMa B 3XH nepHO^bl. B03HHKHOBCHHIO <j)ypyHKyjIOB
Hoca cnocoGcxByrox nepeoxnaacfleHHa, AJiHxenbHbiH HepaimoHanbHbiH pexcHM
ranoBHxaMHHO3bi,
4>ypyHicyjia npoxo^Hx xpn
^HpOBaHHa. Cxafliw ranepeMHH xapaKxepHsyexca noKpacHCHHeM o6jiacxn BOJIOCXHOro (JionjiHKyjia. j]jnHxejibHocxb SXOH cxa^HH KpaxKospeMeHHa — HecKOJibKo nacoB.
BojibHoro HHHero ne 6ecnoKOHX HJIH HMeexca sy^, He6oin,iiiaa 6ojie3HeHHOcxb B 06jiacxH BocnaneHHoro (})OJuiHKyjia. O6mee COCXOHHHC ne cxpaaaex. B^oxCTHO^
4>opMHpyiomerocJi <j)ypyHKyjia ynjioxnaexcfl, ranepeMHH
ycHJiHBaexca, npnoGpexaa sacxoHHbiH xapaKxep. B nojpcoHCHOH KJiexnaxKe najibnaxopHO onpeaejMexca HH(J)HJibxpax. PacnpocxpaneHHOcxb HH(j)HJibxpaxa 3Ha4HxenbHO
BapbHpyexca (ox HecKOJibKHX MHJiJiHMexpOB /jo BOBJieqeHHa BepxHCH ry6bi, noflKO*HOH KJiexnaxKH meKH). Bpn SjiaronpnaxHOM XCHCHKH 4>ypyHKyjia HH<J)HJibxpax pacnpocxpaHaercfl na HecKOJibKo MHHUHMCXPOB BOKpyr Bonoca. O6mee cocxoaHne
6ojibHoro HC cxpa^aex, GecnoKonx 6ojib B oSjiacxn (j)ypyHKyjia.
XCHCHHIO (J)ypyHKyjia Hoca cnocoScxByrox: BbmaBJiHBaHHe (JjypyHKyjia,
XOHajIbHbIM KpCMOM, HCKBajIH^HUHpOBaHHaH HHUH3HH 663 COGjUOACHHS aCCHTHKH.
3a6ojieBaHHaM napyacHoro noca cnoco6cTByK>T SKCcyaaxHBHbiH .anaxes, noBepxHocxHbie rpaBMbi — uapanHHbi, xpemHHbi KO>KH, Koxopbie 6ojibHOH HanocHT
najibHCM npH syae noca HUIH HCOCTOPTOKHOM yaajieHHH Kopox npeAaBepna noca.
3K3CMa KO5KH ciiHHKH H npCAzjBepHa Hoca — nacTHoe npoHBjieHHe aiuieprHqecKoro aepMaraxa, nosTOMy nepejiKO conexaeTca c SKSCMOH jiHua H BOJIOCHCTOH
qacTH ronoBbi. HsMCHCHHaH K05Ka rnnepeMHpoBaHa, cicerKa oienHa. Ha HSMCHCHHOH nOBCpXHOCTH HMCIOTCa yH3CTKH MOKHyTH^, BC3HKyjIbI, KOpOHKH. IlO-
CKOJibKy saSojiesaHHe conpoBoxyiaeTca sy^oM KO»CH, Hepe^KO B oGnacxn noca,
meK HMeroTca qapanHHbi. IIoBepxHOCTHbie xpaBMbi HSMeneiiHOH KO>KH CIOIOHHW
K SbicrpoMy HH(J)HHHpoBaHHio H Hacxo HarHaHBaioxca. 3K3CMa npeaaBepna noca
Moacex ocjio^HHibca 4>ypyHKyjie3OM HJIH POHCHCTWM BocnaneHHCM.
saKJHonaerca B co6jnofleHHH rHnoaiuiepreHHOH flHerw, nasHaqeHHH
npenapaxoB. /^Jia MCCTHOFO JieneHHa na MOKHymne ynacxKH naBJia»HO-Bi>icbixaK)mHe nosasKH c UHIIKOBOH 6ojixymKOH, <J)ypauHJiJIHHOM. Koacy npe/mBepHfl noca o6pa6axbiBaiox MasaMH, coaepacauiHMH anxHcenXHKH H aHajiora cxeponanbix FOPMOHOB: Baxpa(J)eH, Tpn^epM, <6yu,HKOpx H ap.
OypyHKyji npezwBepHH Hoca — 3a6oiieBaHHe, xapaicrepHoe fljia B3pocnwx
(CM. pHc. 9 IIpnjio5KeHHH). Y flexen paHHero Bospacxa <})ypyHKyjibi aoca BcxpeKpaHHe pe^KO. ITpHqHHOH 4>ypyHKyjia MOHCCX nocjiy»HXb saneceiiHe HHB caiibHbie ace^esbi H BOJiocanbie MCUIOHKH npH nonecbiBanHH Hoca. Bos(j)ypyHKyjia, KaK npaBHJio, aBjwioxcH cxa(})HJioKOKKH, Koxopwe o6njibHO sacejiaiox ycxbfl canbHbix H HOXOBMX JKCJICS BOJiocaHbix 4>OJinHKyjioB.
HaH6ojiee Macro Bcxpenaioxca (jjypyHKyjibi y aexen npeny6epxaxHoro H nyGepxaTHoro BospacroB, HXO CBHSEHO c aKXHBHsaaHCH pocxa BOJIOC npeAAsepHH noca H
YcyryGjiaex xeneHHe 3a6oneBaHHfl BbicoKaa BHpyjieHXHOCXb MHKpo(})jiopbi, 3HflOKpHHHbie saGojieBaHHH H HMMyHOfle(j)HUHXHbie COCXOSHKH, paBHO KaK H raneppeaKXHBHOCXb HMMyHHOH CHCxcMbi, xapaKxepHaa fljw npeny6epxaxHoro H nySepxaxHoro
Bospacxa. O6mee cocxoaHHe GojibHoro Moacex 6bixb ox yAOBJiexBopHxenbHoro no
KpaHHe XHHcejioro npn OCJIO^CHCHHOM xeMCHHH. JlnxopaaKa KOJie6jiexcfl ox cy6<|)e6PHJIBHOH ^o reKXHnecKOH npn passHXHH cencnca. ynnxbisaa BOSMoacnocxb pasBHXHfl
BHyxpHHepenHbix ocjioxoieHHH, Bee 6onbHbie <J)ypyHKyjiOM Hoca y»ce B OXCHHOHH4)HJlbXpaXHBHOH CXajJHH flOJDKHbl 6bIXb roCHHXaJIH3HpOBaHbI B JIOP-OXfleJieHHC. B
cxMjui_a6cLie,aHpoBaHHH ynacxoK HH(J)HJibTpaxa BOKpyr BOJioca pasMarnaexca, <J>opMHpyexca rHOHHblH cxep>KeHb. HepeflKO rojioBKa cxep»cna (J)ypyHKyjia npocBCHHBaex
nepes Koacy B Btme seJieHOBaxoii OKpyrjion XOHKH.
FIpH FHOHHOM BOCHaJICHHH HCCKOJlbKHX BOJIOCHHblX (})OJIJIHKyjIOB paSBHBaeX-
CH KapGynKyji. B SXOM cjiynae onarn rHOHHoro pacnjiaBjieHHa HOAKoacHOH KJICXnaxKH cjiHBajoxca, o6pa3y» e^HHyio nojiocxb c MHOHcecxBennbiMH
rHOHHbix cxepacHCH Ha nosepXHOcxb KOJKH.
Us OCJIOHCHCHHH (})ypyHKyjia MO^HO BbiAeJiHXb^jiH
H noaGopoflOHHOH oSjiacxn (naHGojiee xapaKxepnbie ana ACXCKOro Bospacxa), xpOM6os noBepxnocxHbix BCH Jinqa, BHyxpHHepennbie OCJIOMCHCHHS:
xpoM6o3 nemepHcxoro CHHyca, MenHHrHX.
Jlenenue. B oxeHHO-HH^HJibxpaxHBHyio cxaflHio jieweHHe (J>ypyHKyjia KOHcepBaxHBHoe, B cxa^Hio aGcqeflnpoBaHHa — xHpypraHecKoe. MCCXHO (B npe/iflBepne Hoca, na KO^cy BepxHCH ryGbi, CHHHKH Hoca) B oxeHHO-HH(j)HJibxpaxHBHyK)
cxaflHK) Hcnojibsyrox cnnpxoBbie pacxBopbi anxncenxHROB ((jjypauHJUiHHOBbiH,
6opnbiH cnnpx), Masn c anxnGHOXHRaMH (xexpaHHKJiHHOBaa, renxaMHUHHOBaa,
108
TeMa VII. SAEOJlEBAHI/lflHOCA M OKOJIOHOCOBblX FIASYX
_
, cnoco6cxByK>uiHe
HOMy BCKpwxHio (J>ypyHKyjia, yMCHbinaiomHe PHCK raoHHoro paciuiaBJieHHa no/iKO5KHOH KJiexnaxKH (nxxHOJioBaa, JieBOMCKKOJib, SaubsaM BHiiiHeBCKoro). Ha
^ (J>opMHpoBaHHa <})ypyHKyjia 3(J><|>eKXHBHo
XOKOB YBH, MHKpoBOJiHOBOH xepanHH.
4>yBCKpbiBawx, nojrocxb (J)ypyHKyjra o6pa6aTbiBaK>x 3 % nepeKHCbro
a, BBOJXHX B nee xypyn^w c rnnepxoHHHecKHM pacxBopOM, c uejibK)
ycxaHaBJIHBarox FIOJIOCKH nepnaxoHHOH pesHHbi. flpennpOBaHHe (J)ypyHKyjia npoflOJDKarox AO nojiHoro OHHiuenHa OOJIOCXH ox rHOHHbix Mace.
Hasnanaexca CHCxeMHaa anxH6aKxepHajibHaa xepanHg_npenapaxaMH innpoKoro cncKxpa fleficxBHa c 6aKTepHUH4HbiM 3<j)4>eKxoM7~Ha3HaHaiox npenapaxu
neHHUHJuiHHOBoro pa^a — Kap6eHHU,HJUiHH, oKcauHJiJiHH, aMOKCHKJiaB, ue<J)a— Ke<})3OJi, KJia(j)opaH, BxopxHHOJIOHbl — UH<J)paH, xasaHHK. Bbi6op
saBHcnx ox xaxcecxn cocxoaHHa 6oiibHoro. OpH 6naronpHHXHOM xeHCHHH (J)ypyHKyjia aHXH6aKxepHanbHbie npenapaxw HasHanaioxca per os, npn ocno»HeHHOM TeneHHH (j)ypyHKyjia Hcnoubsyexca KOM6HHaiiH5i
HMX npenapaxoB, BBeflCHHe ocymecxBJiaexca BHyxpHBeHHO H
HanpHMep, KJia<J)opaH — BHyxpHMbiiiieHHO, Mexpormi — BHyxpHBeHHO. IlpH pasBHXHH pHHOrCHHOrO MCHHHrHXa, TpOM6o33 nCHiepHCXOrO CHHyca B 6oJIbIUHX J10-
sax HasHanaexca poue(})HH, neHHUHJUiHH — ao 60-70 MJIH E,H, B cyxKH. Cpeanaa
xepaneBXHHecKaa pacHexnaa j^osa npenapaxoB neHHiiHJiJiHHOBoro pajja H ue(J)ajiocnopHHOB: 50-100 MF/KT B cyxKH. B cjiynae pa3BHXH» pHHoreHHbix BHyxpHHepennbix ocjioa<HeHHH neHHUHjuiHH paccHHXbmarox 1 MJIH Efl/Kr B cyxKH.
C uejibK) npe^oxBpameHna xpoMSosa BCH JiHua H OOJIOCXH nepena Hasnanarox
aesarperanxH. Opn yaoBJiexBopnxejibHOM cocxoaHHH 6ojibHoro Hcnojibsyiox acnnpHH BHyxpt e^eixHeBHO B jjose 0,125 Mr/cyx. HJIH xpoMSoacc 50 Mr/cyx. IlpH
aBJieHHax xpoM6osa BCH BBOijHxca (J>paKCHnapHH HJIH renapHH noflKowno. BBCfleHHe renapHHa ocymecxBJiaexca noa KonxpojieM KoaryjiorpaMMbi. 7I,exaM renaPHH BBO^HXca HS pacHcxa IOOE/VKF Maccbi xejia na 1 HHbCKUHio. IIoBxopHoe
BBefleHHe ocymecxBjmexca iepe3 4-6 nacoB. Llejiecoo6pa3HO HasnaHeHHe anxHrHcxaMHHHbix npenapaxoB I H II noKOJieHHH — aHMeapona, anasojiHHa, xaserHJia, o6jiaaaiomHX npoxHBOoxeHHbiM H ce^axHBHbiM 3(J)([)eKXOM. UlnpOKO Hcnonbsyexca 6HoreHHaa CTHMyjiaiiHa — ayxoreMOxepariHa, BHyxpHMbiiuenHoe BBe^eHHC npenapaxa «rjiK>Hax», peKOMeHflOBanw HMMyHHbie npenapaxbl — cxa<|)HJioKOKKOBHH raMMa-rjio6yjiHH, cxa(j)HjiOKOKKOBaH iijiasMa. Ilpn HajiHHHH HHXOKCHKau,HH npOBO^axca jjesHHXOKCHKauHOHHbie MeponpnaxHa — B/BCHHaa HH(J>y3Ha
KpHCxajuiOHflHbix pacxBopOB, reMOflesa.
CHKOS (ocxHO(})OJiJiHKynHx) — BocnajinxejibHoe 3a6ojieBaHHe BOJiocHHbix
(j)OJUiHKyjioB npeflUBepHfl noca, Bbi3biBaeMoe cxac|)HJioKOKKOM. Y .nereH npaKXHHCCKH HC BcipenaeTca. CnK03y cnocoScxByex npHBbiHKa Bbipbisaxb BOJIOCH HS
npeflflBepHa Hoca, JiJinxejibHbie BbiflejieHHa HS noca npn xpoHHiecKOM pHHHxe.
riopa>KeHHbra ynacxoK KO»H rnnepeMHpoBaH, oxenen, 6ojie3HeHHWH. BHyxpen-
I. 3a6ojieBaHMfl neperopoflKM Hoca
109
naa nosepxHOCxb Kpbina noca noRpbisaexca noKpbiBaexca GojibiiiHM KOJIHHCCXBOM BocnajieHHbix ({)OJiJiHKyjiOB. MecxaMH OHH npaKXHnecKH npHJie5Kax ^pyr K
apyry H oGpasyrox KOHrnoMepaxbi nycxyji Ha ynjioxneHHOM rnnepeMnpOBaHHOM
ocHOBaHHH. THOH nycxyji sacwxaex B KOPOHKH, HOA KOxopbiMH Haxo^nxca MOKnymaa sposnpoBaHHaa noBepxHOCxb. B yrjiax Hosapeft noaBJiaroxca rpemHHbi.
JleneHue. K Bpaiy 6onbHbie o6pamaioxca, Kor^a B npeaaBepHH noca CKanjiHsaexca 6ojibuioe KOJinnecxBO rHOHHbix KopoK, yqajieHHe Koxopbix onenb 6ojie3HCHHO. JleneHHe CHKOsa /jjinxejibHoe. HaHHHarox JieneHHe c pasMarieHHa KopoK
npe^Bepna noca saKJiaflbmaHHCM B npezmBepne 2-3 % cajuiHqHJiOBOH Ma3H B
XCHCHHC 2-x HCflejib. Ko>Ky o6pa6axbmaK)x pacxBOpaMH anxHcenxHKOB, anxnGHOXHKOB. Do Mepe cxHxaHHH BOcnajiHxeJibHoro npouecca BHyxpeHHroro nosepxHOCXb KpblJIbCB HOCa MO)KHO o6pa6aXbIBaXb 2 % CnHpXOBHM paCXBOpOM 6pHJIJIH-
anxoBOH sejieHH. TpeiuHHbi KO)KH o6pa6axbiBaK)x 10% pacxBopoM HHXpaxa cepeSpa. Ilocjie npeKpameHHa oSpasoBaHHa KopoK B npeaaBepne noca saioiaawBaK)x B xeieHHC Mecaija cnjieHHHOByio Ma3b (10 r cnjieHHHa, no 20 r OJIHBKOBOFO
Macua, BasejiHHa, anrHJipHjia jianojiHHa). B cjiynaax ynopnoro xeneHHa CHKOsa
npOBOflax CHCxeMHyro anxnGaKxepnajibnyro, HMMynpcxHMyjiHpyiomyro xepannio
K3K npn JieneHHH (J)ypyHKyjia noca. BonbHOMy peKOMCH^yiox 3nHJiai;Hio BOJIOC
noca B xenenHe 3-4 MecaijeB.
a. HsojiHpoBaHHoe poxcHCxoe socnajiCHHe KO>KH npcOTBepna Hoca Bcxpelaexca pe^KO, wan;e Bcero BOcnanHxejibHbiH npouecc pacnpocxpanaexca na npejtflBepne Hoca c KOJKH Jinita. npHHHHOH Moryx 6wxb HH(J)HiiHpoBaHHi>ie xpaBMbi KO)KH JiHiia. 3a6oJieBaHHe BbiSbiBaexca naxorennbiMH rnxaMMaMH cxpenxoKOKKOB. 3a6oJiCBaHHe conpoBO)Kflaexca <J)e6pnjibHOH JinxopajiKOH, o3Ho6oM. B saBHCHMOCXH
ox <f>opMbi 3a6ojiCBaHna (spHxeMaxosnaa, Gyjuiesnaa, asBennaa) na JIHUC noaBjmexca HSMeHCHHbiH ynacxoK KO»H c MCXKHMH rpaHHuaMH. Fljiomajib nopa>KeHHOH noBCpXHOCXH MWKCX 6bICTpO yB6JIHHHBaXbCa.
Jlenenue XBKHX 6ojibHbix nposoAHxca B HH^CKUHOHHOH GojibHHue c
aHxn6HOXHKQB neHHUHJiJiHHOBoro pa^a.
II. 3ABOJlEBAHMfl HEPErOPOflKM HOCA
HcKpHB.ieimc IIOCOBOH neperopo^KH. /],eBHai;Ha HOCOBOH neperopo^KH ox
JIHHHH Bcxpenaexca npaKXHHecKH y Kaacfloro ocMaxpHBaeMOro
xa, HO aajieico HC acer^a npH SXOM o6Hapy*HBaexca napymeHHe HOCOBOFO
HHa. B CBasH c SXHM HCKpHBJieHHe HOCOBOH neperopoflKH cnnxaexca naxojioraeH,
HOAJieMcaiyeH JienenHro xojibKO B cjiynae HajiHHHa HapyiiieHHa awxaxejibHoft
4>yHKUHH Hoca. IIpHHHHaMH HCKpHBJieHHa HOCOBOH neperopoflKH aBJiaioxca HHoco6eHHOCXH pa3BHXHa KOCXHOH H xpameBOH xxaHH, o6ycjiOBJinHecooxBexcxBHe pa3MepOB xpameBwx H KOCXHMX nacxefi neperopo^KH
Hoca BepxHKajibHOMy paaMepy HOCOBOH HOJIOCXH. DOMHMO c[)H3HOJiorHHecKHX
110
TeMa VII. SAEOJlEBAHI/lflHOCA H OKOflOHOCOBblX RA3YX
oco6eHHOCxeH HCKpHBJieHHe neperopOARH noca HHHU,HHpyiox xpaBMbi noca, napymeHHa o6MCHHbix npoiieccos B opraHHSMe, B ocoGenHOCXH HapymeHHe o6Mena Kajibnna. ^eBHanna HOCOBOH neperopoaKH HanGonee nacxo Bcxpenaexca B BHAC C-o6pa3Horo HUH S-oSpaanoro HCKpHBjieHna c HajiHHHCM Ha HCH rpeSiia HUH
uinna, HO Moryr Bcxpenaxbca H HHMC cno>KHbie (J>opMfai ae(J3opMauHH.
Fpe6nH ncpcropOARH pacnonaraioxca, KaK npaBHJio, B HHHCHHX ee OTAejiax,
HHoraa nepexoaax Ha AHO OOJIOCXH noca. IIJnnbi HOCOBOH neperopoaKH HMBIOX
saocxpennbiH Konen, KOXopbiH HepeAKO ynHpaexca B HocoByro paicoBHHy.
,H,HarHO3 ycxaHaBJiHBarox na ocHOBaHHH 5Kano6 6ojn>Horo H aanHbix PHHOCKOHHnecKoro o6cjieaoB3HHa. JleneHHe ae4)OPMaUHH HOCOBOH neperopoaKH xonbKo XHpyprHHecKoe. IIpH iiajiHHHH xoJibKO rpe6H« HJIH iimna HOCOBOH neperopOAKH BOSMO>KHO HX JioKanbHoe yaaneHHC noa MCCXHOH anecxesHeH. IlpH HCKPHBJICHHH xpama
neperopoaKH HJIH HannHHH CJIO>KHOH ACcfiopMauHH BbinojiHaexca xHpyprHHCCKoe
BMeuiaxejibCXBO. HaH6o;iee pacnpocxpaHenbi cjieayioiUHe BHAI.I oneparasHbix BMBmaxeJibcxB: cenromiacxHKa HOCOBOH neperopoaKH no KjuuraaHy c peHMiuiaHxauHefi
MOACJinpoBaHHoro ayxoxpama, peApeccauna (HJIH HjipKyjiapHaa peseioiHa) HOCOBOH
neperopoaKH no BoaneKy. OnepaxHBHoe BMemaxejibcxBO nposoaHxca noa Hnxy6aUHOHHblM HapKOSOM, peaKO
noa M6CXHOH aHCCXCSHeH.
Onepau,usi Kwuiuana. Hn^HJibxpaiiHOHHo cjiHsncxyio oSojiOHKy H naaxpamHHuy oxcaaHBaiox ox xpama neperopoaKH H KOCXH pacxsopOM HOBOKaHna HJIH
4>H3HonorHHecKHM pacxBopOM (rHAponpenapoBKa). Do nepexoaHOH CKJiaaKe
Hoca cjiesa BbinojiHaexca paspes MarKHx xKaneH ao xpama neperoHoca. BbiaeJiaexca nexbipexyroJibHWH xpam neperopoaKH noca c JICBOH
cxopOHbi. 3axeM B Mecxe paapesa CJIHSHCXOH BepxHKaJibHO paspesaexca xpam neperopoaKH xaK, ixo6bi He nospeanxb HaaxpauiHHny H cjinsHcxyio apyron cxopoHW, H xaKace oxcJiaHBaexca. Me>KAy JincxKaMH CJIHSHCXOH BBOAHXCS HOCOBOC sepKajio KHJiJinana, BbiaejieHHbiH ae(J)opMHpOBaHHbiH ynacxoK xpama neperopoaKH
Hoca yaajiaexcs, Moaejinpyexca. HcKpHBJieHHbie y^acxKH KOCXHOH nacxH neperoHoca yaajiaioxca oKOHnaxwMH mHnu;aMH, rpeSHH cSHBaioxca mxbiKoo6aoJioxoM. YaaJieHHWH ynacxoK xpama neperopoaKH noca HMnjiaHxnpylox Meacay JiHCXKaMH HaaxparnHHiibi. HHCXKH HaAxpaiUHHUbi co CJIHSHCXOH 060JIOHKOH conocxaBJiarox, saKaHHHBaa onepannio PHXJIOH nexjieBoii xaMnoHaaofi
HOJIOCXH Hoca c asyx cxopon na 48 nacoB.
Pedpeccaifw nocoeou nepezopodKu no Bomevy saicjiiOHaexca B XOM, HXO HCKpHBJieHHbiH yqacxoK xpama neperopoaKH oxcJiaHBaexca ox HaaxpaiuHHUbi H
Bwaejiaexca xojibKO c oanoM cxopoHH. flanee HCKpHBJieHHbiH ynacxoK BbiKpanBaexca yrjiOM oxKpuTbiM Knepeaw, neM aocxnraexca ero Mo6HJibHocxt. Hnoraa BOKpyr BbiKpoeHHoro JiocKyxa npoHssoaax yaaneHne WJIHUIHCH)) HOJIOCKH xpama
peseKuna), HO Bceraa coxpanaexca caasb BbiKpoeHHoro JiocKyxa c
npoxHBonoJio>KHOH cxoponbi. flanee OXCJIOCHHWH JIHCXOK naaco CJIHSHCXOH o6ojioHKOH coeaHHaexca c xpamoM neperopoARH noca,
nojiocxb Hoca PHXJIO xaMnonnpyexca.
II. 3a6ojieBaHH5i neperopoflKM noca
111
TaMnonaaa nojiocxn noca aJinxca asoe cyxoK, nocjie Hero xaMnoHbi yaajiarox, BOccxaHOBHxenbHbiH nepnoa npoaojixcaexca B xeHenne 7-14-H aHeii.
B BOCcxanoEHxejibHOM nepHoae c nejibro yMenbuieHHa o6pasoBaHHa KOPOK
6ojH.HtiM peKOMenzryiox 33KanbiBaTb B HOC MacJWHbie Karmii. Hcno^bsyioTca Macjia
nepcHKOBOe, OJIHBKOBOC, a6pHKocoBoe, easenHHOBoe, MacJWHbie KaruiH «E[HHOCOJI».
Beaenne nonocxn noca MacjianbiMH pacxBopaMH noKasano npn oxcyxcxBHH conyxcxByiomHX BocnajiHxejibHbix 3a6ojieBaHHH nojiocxn Hoca H npHaaxoiHbix naayx Hoca.
Hpn aaHHOM cnoco6e Beaenna ycxpanaexca sya B nocy, HO AOBOJibHO AJiHxejibHbiH
cpOK, ao 7-H AHCH, coxpanaexca (B xoii HJIH HHOH cxencHH BbipaaceHHOcxn) 3axpyAHocoBoro Atixanna. FIoaxoMy xpe6yexca peryjmpHbiH xyanex nojiocxH noca,
BpanoM. CpOKH BOCCxaHOBjiCHHa CJIHSHCXOH oSoJiOHKH HOJIOCXH noca
H HOpMaJIH3aUHH HOCOBOTO AbDCaHHa
OX 7-H AO 14-H AH6H. B BOCCXaHOBHXeJIbHOM
nepnoae BOSMOJKHO HcnojibsoaaHHe yBJia»oiaiomHX Kanejib H cnpees («CajiHH»,
«AKBa Mapnc»), Koxopwc xo»c npenaxcxByrox oGpasoBaHHK) Kopon B HOJIOCXH noca.
B nocjieonepauHOHHOM nepnoae cnocoScxByex pacxBOpenHio H suHMHHauHH rycxoft
CJIHSH H3 nojiocxH Hoca, a xaiOKe yjiynmaex HOCOBOB abixanHe HcnojibsoaaHHe HasajibHoro cnpea «PHHO(J)jryHMyuHJi», coaepacamero 4>epMCHx H cocyaocyxcHBaiomee
cpeacxBO. OcJiTOKHCHHaMH onepaqHH na HOCOBOH neperopoaKe Moryx 6brn>: KposoTeneHHe, reiviaxoMa neperopoaKH noca, a6cuecc. B oxaaneHHOM nepnoae MOMCCX pasBHXbca sanaaeHHe CHHHKH noca, nep(J)opauHa HOCOBOH neperopoaKH.
Upo(f)wiaKmuKa ocjiostCHenuu. /Ijia npeaoxspameHHa sanaaenna cniiHKH HOca peKOMCHayexca coxpannxb B BepXHefi nacxn xpama neperopoaKH Hoca ne MCnee 0,5 CM. Hxo6bi ne oGpasoaajiacb nep<j)opauHa neperopoaKH, peKOMenayexca
npoBoanxb peHMnjianxauHio MOACJinpoBaHHoro ayxoxpama. /],jia npeAOXBpameHHa pasBHxna KpOBOxeneHHa B nocjieonepauHOHHOM nepnoAe H pa3BHxna reMaxoMbi neperopoaKH noca onepanHio saKaniKBaiox xoabKO npn aocxnxceHHH reMocxasa; ne cjieayex coKpamaxb cpOK xaMnonaabi HOJIOCXH Hoca.
FeiviaTOMa HOCOBOH neperopoaKH oSpasyexca npn xpasMe HOCOBOH neperoPOAKH, peAKO — npn BHpycHbix HH(J)eKUHax, conpOBO^AaiomHxca Koaryjionaxneft (rpnnn H Ap-)> H KaK ocJio^cneHHe nocjie onepaxHBHbix BMeiiiaxeJibCXB na neperopoaKe noca. CKonjieHHe KPOBH nponcxoaHx Me»ay xpamoM H naaxpamHHUCH HOCOBOH neperopoaKH. XapaKxepHblH CHMHXOM reMaxoMbi neperopoaKH: nocxenenno napacxaioinee (HHoraa B xeneHne 7-10-H aieS) saxpyaneHHe HOCOBOTO
AbixaHHa. FIpH 3HaHHxeJibHOM pasMepe reMaxoMbi MOJKBX Ha6jnoaaTbca H3MeneHHC Hapy»HOH (j)opMw Hoca. O6teKXHBHo Ha6jnoaaeTca mapoo6pa3Hoe, <$JUOKxynpyiomee pacrnHpenne xpameBoii nacxn neperopoaKH noca. LjBex CJIHSHCXOH
oGojiOHKH Hoca, KaK npaBHJio, ne HSMCHCH, HHoraa HMeexca ee ranepeMHa. OcMoxpexb saanne oxaeabi HOJIOCXH Hoca saxpyaHHxejibno.
Jlenenue. UlnprmoM npoBoaarr nyraomioreMaxoMbic oxcacbisaHHeM ee coAep^cnMoro. JTlocJie 3xoro nojiocxb Hoca xyro xaMnoHHpyexca c asyx cxopon, HasHanaioxca
aHXHGaicrepHajibHbie H reMocxaxKraecKHe cpeacxsa. IIpH noBxopnoM oSpaaoBamoi reMaxoMbi ee neofixoaHMO BCKpbrrb H apennpoBaxb noaocxb ao cxaSroibHoro reMOCxasa.
112
Teiwa VII. SABOJIEBAHUflHOCA M OKOJlOHOCOBblX RA3YX
AScuecc HOCOBOH neperopo/jKH o6pasyexcH BCJieacxBHe HarHoemia reMaxoMbi
neperopoflKH noca, HHoraa — npn xonaonepHxoFtnpHxe xpama neperopoflKH. KpanHC peflKo npouecc MOHCCX HMexb oflonxorcHHtiH xapaKxep. CHMIIXOMH 3a6ojieBanna
xe »ce, HXO H npn reMaxoMe neperopo.zucH, HO noaanaioxca »ano6bi, xapaicxepHbie jxrca
BOcnajiHxejibHoro npoqecca: rojioBHaa 6ojib, Jinxopaflica, He^oMoraHHe H x. fl. O6teicxHBHaa KapxHHa xaicaa nee, KaK H npH reMaxoMe HOCOBOH neperopoJXKH.
Jlenenue saKJUonaexca BO BCKpbixHH H flpeHHpOBaHHH aQcuecca. IIpH scicpbrraH
a6cuecca co6nio/iaexca npaBuno: paspesbi CJIHSHCXOH oGojioiKH nponsBOflax c flsyx
cxopOH, Ha pasHbix ypoBiwx H B paaHbix raiocKocxax. Hojiocxb aGcuecca o6pa6axbiBarox pacxBOpOM nepeKHCH Bo^opofla, npoMbreaiox aHxn6HoxHKaMH, #peHHpyiox
nepnaxoHHOH pesHHOH. BonbHbiM HasHanaiox CHCxeMHyio aHXH6aKxepHanbHyio, npoxMBOBocnanHxejibHyio xepannio. OcjioatCHemtx a6cu,ecca neperopo/nai noca: sanajjeHHC COHHKH HOca, oSpasoBaHHC nep4>opauHH HOCOBOH neperopoaKH. He HCKJUOHCHO
Ml. BocnannrenbHbie 3a6ojieBaHMH nonoc™ Hoca
113
Hoca, KpoBenanojiHeHHe cocy/ioB SHannxejibHO yBCJiHHHBaexca, pasBHBaexca seHO3HWH 3aCXOH KpOBH B nemepHCXHX CHJlCXCHHaX HOCOBblX paKOBHH, HXO 3a-
xpyflHaex HOCOBOC /ibixaHHe. CeKpexopnaa aKXHBHOCXb CJIHSHCXWX TKCJICS noBbimaexca. AKXHBHOCXb HasajibHOH cenpeuHH saBHCHx ox BO36yjjHxeJia ocxporo pnHHxa. HanpHMep, npn aaeHOBHpycHOH HH^CKUHH pnHoppea HOCHX npo<J>y3HbiH
xapanxep, a npn rpnnne ceicpeuHfl CJIHSH KpaHne cKy^na. B jno6oM cjiynae HSMBneHHe ceKpexopHoii aKXHBHOCxH cjiHSHCXbix acejies BC^CX K HSMeneHHio cocxasa'
CJIHSH, Hapyiiiaex pa6oxy Mepu,axejibHoro annxejiHa, npHBO^nx K HacxHHHOH noxepe pecHH^eK MepijaxejibHoro snnxeJiHa, cnoco6cxsyex KOJiOHHsaiiHH MHKpo(J)JIOpbI Ha CJ1H3HCXOH oGoJIOHKC. B OXBCX Ha BHejrpCHHe HHObeKUHOHHblX arCHXOB
B cjiH3Hcxyio Hoca aKXHBH3Hpyexca cncxeiwa HMMyHHxexa. Cjinsncxaa HH(J)Hjibxpnpyexca JiHMobouHxaMH, HeHxpo(j)HJiaMH. MejiKOKJiexoHHaa HHCJMJibxpauHa oco60 BbipajKCHa BOKpyr cocyjjoB H CJIHSHCXWX
paSBHXHC BOCnajIHXCJIbHblX BHyipHraaSHHHHblX H BHyipHHCpenHblX OCJ10KHCHHH.
B X6H6HHH OCXpOrO pHHHXa BblJ^CJIHIOX XpH
KpOBOTonaiuHH no.inn HOCOBOH neperopoflKH Bcxpenaexca npeHMymecxBCHHO y 6epeM6HHbix >KeHUJiHH HJIH 6ojibHbix c HapyiuenHaMH o6ivieHa BemecxB, HXO no3BOJiaex npeflnojiO)KHXb B KanecxBe sxHOnorHHecKoro (J)aKxopa HSMeHCHHe 3HflOKPHHHOFO cxaxyca opranH3Ma. XapaicrepHbie 5Kano6bi npH 6one3HH — oanocxopoHHee
saxpyaHCHne HOCOBOFO flbixanna H peuHflHBHpyiomHe nocoBbie KpoBOxeneHHa c SXOH
ace cxopOHbi. Flpn PHHOCKOHHH onpeAejwexca nponspacxaiomee H3 xpameBOH nacra
HOCOBOH neperopoflKH 6arpOBO-KpacHoe HOBOoSpasoBaHHe na KopoxKOH HOMCKC. Flpn
I cxa^Ha — «cyxaa»;
II cxaana — 3KccyjjaxHBHaH (ceposnux, CJIHSHCXMX, cjiH3HCxo-rHOHHbix BH-
30HaHpOBaHHH HOJIHOa H3 H6rO JieiTCO BOSHHKaCX KpOBOXCHCHHe.
III cxaflHa — paspeuieHHa.
HaHHHaexca ocxpbiH PHHHX c »cajio6 na cyxocxb, MOKCHHe, 3yA B nocy.
KOM(J)opx nepeziKO ycHJiHBaexca nacxbiM nnxaHHCM. FIoaBJiaexca
Hoca, CHHwaexca o6oHHHHe. .fljinxca I cxa^na ox 1-2 nacoB flo 1-2 cyxoK. B nocjieflyKimHe JJHH (HJIH nacbi) noaBJiaioxca BbiJjejieHHa H3 noca (II cxaflna). Kpax-
JJenenue xHpyprHHecKoe. IIpHMeHaiox ncceneHHe nonnna BMecxe c OKpy-
KOBpeMCHHO HOCOBOH CCKpCX aBJiaCXCa CepOSHbIM (BOJjaHHCXbIM), 33XCM BblflCJie-
5KaK>IIIHM y^aCXKOM CJIH3HCXOH o6oJIOHKH H nOflHeMCaiUHM JIHCXKOM HaJJXpaiUHH-
HHa npHo6pexaK)x CJIHSHCXHH xapaKxep. Hocosaa cjinsb eme 6ojibuie saxpy^Haex
HOCOBoe AbixaHHe. CnH»caexca annexHX, Hapymaexca COH. Hasajibnaa o6cxpyKUHa cnocoGcxsyex noaBJieHHio FOJIOBHOH GOJIH. OxcyxcxBHe HOCOBOFO jjbixaHHa
KOMnencHpyexca flbixanneM poxoBbiM, HXO Be^ex K pacnpocxpaneHHio BOcnanHxejibHbix H3MeHCHHH Ha HHXcejiexcamHe ox^ejibi ^wxaxejitHbix nyxen. nocxenenHO BocnajiHxejibHbiH 3Kccyaax cxanosMxca cjiHSHcxo-raoHHbiM HJIH npeHMymecxBCHHO rHOHHbiM, Ba3Kocxb HOCOBOro ceKpexa yBejiHHHBacxca. Do Mepe yMCHbmeHHa ocxpoxw socnajieHHa o6ieM HocoBbix paKOBHH yMenbuiaexca, yjiynmaexca HOCOBoe jjbixaHHe. B III cxajjHH KOJinnecxBO ox^ejiaeMoro HS HOJIOCXH noca
yMeHbmaexca. Hnor^a BbwejicHHa H3 noca cxanoBaxca nacxojibKO rycxbiMH, HXO
xpy/lHO oxcMapKHBaroxca, o6na^aa BHCOKOH KJieHKOCXbro K CJIHSHCXOH o6oJioHKe
Hoca, o6pa3yiox raoHnwe KopKH. O6iuaa jjjiHxeJibHOCXb Heocjio)KHeHHoro HH<})eKUHOHHoro ocxporo pHHHxa cocxasjiaex OKOJIO 7-10-H /(Hefi. /l,HarHO3 ycxaHaBJiHBaexca na ocHOBaHHH xcajioO H ijaHHbix PHHOCKOHHH.
flHarnos npOBOflHxca c HH({)eKH.HOHHbiMH 3a6ojieBaHHaMH,
qbi. Kpaa panti Koaryjinpyiox. npH rHcxojiorHHCCKOM nccjieaoBaHHH KpOBOxonojinna HepeflKO BepH(j)HUHpyexca
III. BOCnAJlHTEJlbHblE 3AEOJ1EBAHklf1 nOJIOCTH HOCA
H pHHHT (oSbmHWH HaCMOpK) - OCXpOe BOCnaJICHHC CJIH3HCXOH
HOJIOCXH Hoca, conpoBoacflaioineeca paccxpoficxBOM 4>yHKUHH HOJIOCXH
Hoca. Hame Bcero ocxpHH PHHHX — 3a6oJieBaHHC HH^CKUHOHHOC, BbiSbiBaeMoe
BHpycaMH H SaKxepnaMH, no nycKOBbiM MOMCHXOM MO^KCX nocnyacnxb BHesannoe
CHJibHoe pasupaaceHHe CJIHSHCXOH Hoca nbiJibK), CJJ;KHMH rasaMH H XHMHHCCKHMH
BemecxsaMH. Onpe^ejieHHyio pojib nrpaex o6mee nepeoxjiaayieHHe H oxjiaayieHHC oxflejibHbix Hacxeii xejia, Hame Bcero — cxon. HH^CKUHOHHWH ocxpbiH PHHHX xapaKxepnsyexca cesoHHOCxbio, npnHHMaa xapaKxep snHfleMHH B oceHHeBeceHHHH nepnofl. Pacnpocxpanaexca HH<J)eKi;HH BO3JD,yuiHO-KanejibHbiM nyxeM,
nosxoMy CKyneHHOcxb jnoaefi B o6mecxB6HHbix Mecxax (uiKOJiax, paGo^nx KOJIjieKXHBax, xeaxpax H x. fl.) cnoco6cxByex jjHcceMHHaiiHH pHHHxa cpe^H nacejieHHa. BocnajiHxejibHbiH npouecc saxparHBaex BCK> xonmy CJIHSHCXOH o6oJiOHKH
pHHO-(J)apHHrHXOM (KOpb, flH({)XepHa, MeHHHFOKOKKOBaa HH^eKUHa H X. JJ.).
OCJIOOKHCHUJIMU ocxporo pHHHxa aBJMJOxcfl name Bcero ocxpwH cHHycnx H
ocxpbie cpejiHHe OXHXU. OiiHaKO He HCKJHOHCHO pasBHXHe BHpycHoro HJIH 6aKxe(name MeHHHroKOKKOBoro) MeHHHrnxa.
114
TeMa VII. SAEOJlEBAHMflHOCA M OKOJIOHOCOBblX HA3YX
I. Bocna^HxenbHbie 3a6oneBaHMfl nonocxu noca
Jlenemie. B nepBbie nacw saGojieBaniw uejiecoo6pa3HO saKanbisaHHe B HOC JICHKouHxapHoro HHxep<})epoHa, saKJiajxtiBaHHe OKCOJIHHOBOH Masn. C Hcnbio yMeHbiueHHa syna, cyxocxn B nocy MOHCHO ncnojibsoBaxb MaciwHbie KanjiH «IIHHOCOJI», nep-
I. XpoHHHecKHH KaxapanbHbiH PHHHX.
II. XpOHHHCCKHH rHHepXpO(J)HHeCKHH pHHHXI
<})opMa (BasoMOxopHbift PHHHX, ajuieprHHCCKaa pHHOCHHyco-
CHKOBOC, OJIHBKOBOC MaCJIO, MaCJlHHHH paCTBOp BHXaMHHa E. ITpH OXCyXCXBHH JIHXO-
panKH c uejibio ynynuieHHa HOCOBOFO flbixaHHS MOJKHO npHMenaxb cyxne xeruioBbie
npOHC/rypbi Ha cnnHKy noca, oxaneicaiomyio xepanHio (ropanne Hoxcnbie saHHbi,
ropMHHHbie o6epxbiBaHHa cxon H x. A.). 3<Jxj)eKXHBHO YOO Hoca H sesa. Opn HOHBJICHHH FHnepeprHHCCKOH peaion™ opraHHSMa noKasano npOBCAeHHe CHCXCMHOH
xepanHH: npoxHBOBOcnanHxenfaHOH, fleceHcnGHUHSHpyiomeH H anxHOKCHAanxHOH.
Bnyxpt SoiibHbiM peKOMCHjryiox npHHHMaxb pacxBOpHMbie xa6nexKH acnnpHHa,
<J)H6po3Haa (})opMa:
(nojinnosHflHaa, <}>H6pO3Haa, Kocxnaa, rnnepBacKy, KOM6HHHpOBaHHaa).
III. XpOHHHeCKHH axpO(J)HHeCKHH pHHHX:
• npocxoft axpo(})HHecKHH
4>opMa;
4)opMa;
aCKOp6HHOBOH KHCJIOXbl. Bo BXOpOH CXaflHH JICHCHHe 33BHCHX OX BblpaHCCHHOCXH Ha-
saiibHOH ceKpeuHH. Opn npo(j)y3Hbix cep03Hbix, cnHsncxbix BbmeneHHflx pauHOHajibHO HcnojibsoBaHHe nepopanbHbix fleKOHrecxanxoB, coziep5KamHX <J)eHHji3c|)pHH, nces(«KoHXaK», «KoJm3K»). FIpH yMCpCHHOH 3KCCyaaUHH 6ojlbHHM peKO-
HHTpaHasantHbie ^eKOHrecxanxw B BH^C Kanenb (Ha(})XH3HH, HasHBHH, raHJIH cnpeeB («KcHMejiHH», «Ha3OJi», «/lJiaHoc»). TaioKe HasHanawx sananwBaxb B HOC npoxHBOMHKpo6Hbie npenapaxbi (20 % pacxBOp cynb(J)annjia-HaxpHH,
0,5 % ^HOKCH^HH H X. £.). IlpH rHOHHblX BbmejICHHflX H3 HOCa pCKOMeHflylOX HHXpa-
nasajibHoe saioiaabiBaHHe Maseft c anxnGnoxHRaMH, npHMCHCHHe cnpea «BnonapOKC». Ilpn yxynxueHHH oGuiero caMOTyscxBHa HasHaqaexcx CHCxeMHas npoxHBOBOcnajiHxejibHaH xepanna, Hcejiaxeubno B EH^C ropHnero nnxba («Coldrex Hotrem»,
«Tepa-4mio», «3<})4)epajiraH» H x. ^.). Heo6xo^HMO ynoxpe6jieHHe B 6ojibuiHX ^osax
C. CxHMyjrapyex aKXHBHOCXb sauiHXHbix peaKUHH opraHH3Ma H HOXOOXACH, cnocoGcxsyer sjiHMHHaiiHH BHpycoB H3 opraHHSMa npHMeneHHe BHyxpb roHacxoa area cyxoft Mannnbi, ropanero naa c MC^OM c nocjieayroiuHM o6mHM
nporpeBaHHCM. B III CXHJIHH npn HajiHHHH BSSKHX rHOHHbix BbmeneHHH, Koxopwe
xpyzmo oxcMapKHBaroxca, 6oJibHbiM peKOMeHflyiox HcnonbsoBaxb xenjibie naposbie
HnrajxauHH. 3(j)(J)eKXHBHO onnmaex nojiocxb Hoca cnpefi «PHHO(j)JiyHMyuHji». Ilpn
CKJIOHHOCXH K 3axfl>KHOMy xeqeHHK) HacMOpxa peKOMCH^yiox Hcnojib30Baxb npenapaXH xnna «CHHynpex», cocroamHe HS pacxnxeJibHoro ctipta, cnoco6cxByK>m.He BOCcxanoBJieHHK) pa6oxbi MepuaxejibHoro snHxejiHa HOJIOCXH noca.
IJpcxpwaKmuKa ocxporo pHHHxa CBasana co cBoeBpeMCHHOH BaicaHHauHeH nacejieHHa ox rpnnna, npHMCHCHHeM HMMyHocxHMyjiHpyromHX cpejicxs («HPC-19»,
«PH6oMyHHJi», «BpoHXOMyHaji» H ap.), npo4)HJiaKXHKOH rHOOBHxaMHHOsa. B nepnoa snHflCMHH rpnnna B ZICXCKHX KOJineKXHBax, 6oJibHHiiax npOBOflaxca KapaHXHHHbie Meponpnaxna.
XpOHBHCCKHC pHHHTbl. E^HHaa KJiaCCH(})HKaUHa XpOHHHeCKHX pHHHXOB OX-
cyxcxsyex. YnnxbiBaa, HXO MOp(J)OJiorHHecKH XPOHHHCCKHH BOcnajinxejibHWH
npouecc nocJie^OBaxeiibHO npoxo^nx xpn cxa^HH — KaxapajibHyro, rnnepxpo({)HnecKyro H axpo4>HHecKyio, BCC BopMbl xpoHHHecKHX PHHHXOB name Bcero CBOflax
K 3XHM cxa^naM c yKasaHHCM Mop<})OJiorHHecKHx oco6eHHocxeH. IlpeacxaBjiaexca
yflo6HHM KJiaCCHCJJHlJHpOBaXb XpOHHHCCKHH pHHHX CJICflyKJiyHM o6p330M:
115
• 3JIOBOHHbIH axpO(})HHeCKHH
XpoimqecKHii KarapajibHbiH PHHHT. B SXHOJIOFHH xpoHHHCCKoro KaxapajibHoro pHHHxa BaacHyio ponb nrparox nacxbie pecnnpaxopHbie HH^CKUHH H
ajiHxejibHoe oxjiaayieHHe. Pa3BHxnio xpoHHHCCKoro KaxapanbHoro pHHHxa cnoco6cxByex peryjiapnoe npeOtiBaHHe B sanbineHHbix, saraaoBanHbix noMemenHax.
Onpe^eJieHHyio ponb HMCCX sarpasHCHHe OKpyacaromen cpeflbi. TaK, ropoflCKne
5KHXCJIH 6OJI6K)X XpOHHHCCKHM K3XapajIbHbIM pHHHXOM HaiUC, HCM HaCCJICHHe
ceiibCKOH MCCXHOCXH. KaxapajibHbiH PHHHX nepe^KO conyxcxByex naxonorHH HOCOFJIOXKH H OKOJIOHOCOBHX riasyx, aBJiaacb B SXHX cjiynaax BXOPHMHHM 3a6ojieBaHHCM. HanpHMep, npn a^eHOH/jax, xpOHHHecKOM a^eHOHflnxe B HOJIOCXH Hoca
pa3BHBaexca jiHM(j)axHHecKHH cxas, HXO cnoco6cxByex oxexy CJIHSHCXOH noca,
noBbimeHHK) cjiHseoxACJieHHH, HapyiueHHK) pa6oxbi MepnaxejibHoro siraxejina,
KOJIOHHSaUHH 6aKXepHH H3 CJIH3HCXOH. BoCHajIHXejIbHbie HSMCHCHHa CJIH3HCXOH
Hoca conyxcxByrox xpoHHieCKOMy BocnajieHHK) npHaaxoHHbix nasyx Hoca. BHpaweHHOcxb HSMCHeHHH 33BHCHX ox <|>opMbi xpOHHHecKoro CHHycHxa, ero aaBHOCXH,
BHpyjICHXHOCXH MHKpO(J)JIOpbI. Mop(})OJIOrHHeCKHe H3MCHeHHH CJIH3HCXOH
Hoca npn xpOHHHecKOM KaxapanbHOM PHHHXC saicnioHaioxca B HCXOHHCHKH H onaroBOH MexannasHH MepijaxeJibHoro annxejina. B nozpnHxejiHanbHOM cjioe Bbipa*eHa MejiKOKJiexoHHaa HH(j)HJibxpauHa xKanen co CKonjieHHaMH KJICXOK BOKpyr
yCXbCB CJIH3HCXHX JKCJICS. CaMH CJIH3HCXbI6 5KCJie3bI paCUIHpeHbl.
HOM XCH6HHH pHHHX3 B HO/OnHXejIHaJIbHOM CJIOC MOiyi Ha6jHOflaXbCa
CKJieposa.
KnuHUKa. OcHOBHaa >Kano6a y SojibHbix XPOHHHCCKHM KaxapajibHbiM PHHHXOM — nocxoHHHbie BbiaeJieHHa HS Hoca CJIHSHCXOFO HJIH cjiHSHCxo-rHOHHoro xapaKxepa. KOJIHHCCXBO BHACJICHHH MTOKCX SHannxejibHO HSMenaxbca B sasHCHMOCXH ox BpeMeHH rofla, (JjHSHMecKOH HarpysKH, BpeMCHH cyxoK, xeMnepaxypHoro
peacHMa H x. ^. Ha SHannxejibHoe HapyiueHHe HOCOBOFO flbixaHHa 6ojibHbie >Kajiyioxca pe^KO, name BCCFO saJioaceHHOcxb noca caasana co CKonjieHHCM HOCOBOro cenpexa H nocjie oxcMapKHBanHa npoxo^nx. Hepe^xo 6ojibHbie oxMenaiox nonepeMCHHyio sanoaceHHOcxb HOJIOBHH HOCOBOH HOJIOCXH B ropnsoHxajibHOM no-
116
Tewa VII. 3AEOJlEBAHHflHOCA M OKOJIOHOCOBblX HA3YX
jio>KeHHH: B nojioaccHHH Ha neBOM 6oKy yxyfliuaexca flbixaHHe nepes jieByro nojioBHHy Hoca, npH noBOpoxe na apyroH 6oK abixanne nepes jieByro nonoBHHy
BOCcxaHaBJiHBaexca, a nepes npaByio 6bicxpo yxyauiaexca. ITpn PHHOCKOHHH oxMenaexca sacxoftnaa rnnepeMHa HOCOBHX paKOBHH, HajiH4ne cjiHSHCxo-rnoHHoro
oxflenaeMoro B iieGonbiuoM KonHnecxBe B pasnux yiacxKax HOJIOCXH noca 6es
H3HK)6jieHHbix jioKajiHsauHH. riocne oxcMapKHBaHHa oxflenacMoe B HOJIOCXH noca
Sbicxpo CKaruiHBaexca BHOBb.
Jlenenue. 3<})4)eKXHBHoe jieneHHe BOSMO>KHO xonbKO B cjiynae ycxpaneHHa
3XHOJIOrH4eCKHX (J)aKXOpOB, npH HCO6XOAHMOCXH
KOppeKUHH HOCOBOFO
HHH. npOBOflHxca jie4eHHe B cneflyiomHX HanpasjieHHax: HOpMajiHsauHa
xpyaa H ox^bixa, Kypcbi o6meyKpenjiaiomeH xepanHH (HMMyHOCXHMyjiaxopbi, anxHOKCHfl3HXH, BHxaMHHbi, 33K3JiHBaHHe), MCCXHOH npoxHBOBOcnajiHxejibHOH xepanHH (cepe6poco/iepHcamHe pacxBopw: Komiaprona, noBHaprona, npoxaprona B
BospacxaiomHx KOHueHxpauHax ox 1 % no 3 %, apoMaxepanna Mace^ 3BKajiHnxa,
Keapa, naHHoro Aepesa), canaxopno-KypopxHoe jieieHHe na KUHMaxHiecKHX Kypopxax C MOpCKHM H BblCOKOFOpHHM KJIHM3XOM.
XpoHHHecKHH rHnepxpo(|)HHecKHH puHHT. SxHOJiorHa, naxoreHC3 H neneHHC (j)H6pO3HOH H K3BepHO3HOH 4>OpM XpOHHHCCKOrO rHHepXpO<})HHeCKOrO pHHH-
xa SHaHHxeiibHO oxjinnaexca, HXO nossojiaex paccMaxpHBaxb 3XH 3a6ojieBaHHa Kaic
caMocxoaxenfaHbie HosonorHHCCKHe (JiopMbi.
XpouwecKuu easoMomopnbiu punum (neHpo-BerexaxHEHaa (J)opMa xpOHHHeCKOFO KasepHOSHoro rHnepxpo(J)HHecKoro pHHHxa). IIpH BasoMOxopHOM pHHHxe
HMeexca Jioacnaa rHnepxpo(j)Ha HOCOBHX paKOBHH, xo ecxb pasMep HOCOBWX paKOBHH (name — xonbKO HH^CHHX) yBejinneH sa cnex oxeica CJIHSHCXOH
napexHHecKoro paciiiHpeHHa cocy/jOB KaBepnosHbix xen nocoBbix paKOBHH.
qHHa BasoMOTOpHoro pHHHxa — HapymeHHe perynaiiHH cocy^Hcxoro xonyca
nO^CJlHSHCXblX B6H03HbIX CnJICXeHHH HH5KHHX HOCOBHX paKOBHH H OXflCJIbKHX
ynacxKOB cpe^KHX HOCOBHX paKOBHH. K pa3BHXHK) BasoMOxopnoro pHHHxa MO»ex npHBecxH rao6oe naxojiorHHecKoe cocxoaHHe, Kacaiomeeca H3MeHCHHa (J)HSHOJiorHHecKoro HOCOBOFO AbixaHwa, fleaxe^bHOCXM cepAeiHO-cocyAHCxoH H
H6Hpo-3HaoKpHHHOH cHcxcM. TaK, Hepe^Ko BasoMoxopHbiM pHHHxoM cxpa^aiox
C HCKpHBJieHHCM HOCOBOH HeperOpOaKH, C FHnepXOHHHeCKOH 6oJie3HbK), C
ocxeoxoH/iposoM, c ropMOHajibHHMH HapyiueHHaMH. Bbi/iejiarox oco6oe
cocxoaHHe — BasoMoxopHbiB PHHHX 6epeMCHHbix.
KjiuHum. Bce 6oJibHbie 6es HCKHK)HeHHa xcajiyioxca na saxpy^HeHHe HOCOBOro flbixanna, MWKCX BO3HHKaxb noonepeAHaa sajiOHcemiocxb HOUOEHH nonocxH
Hoca. O6HJibHbie BbijieiieHHa HS noca 6braaiox xonbKO npH HacnoeHHH ocxpOH
pecnnpaxopHOH HH<j)eKLiHH, K Koxopofi flaHHaa rpynna 6onbHbix aocxaxoHHO BOCnpHHMHHBa. IlOCKOJlbKy pa3MCp HOCOBHX paKOBHH 6bICXpO H 3HaHHXeHbHO CO-
Kpamaexca npn anruiHKauHH cocyAOcy»CHBaiomHX cpeflcxa, MHorne 6onbHbie
npnSeraiox K fljiHxenfaHOMy H nacxoiviy HcnonbsoBaHHio HHxpaHasajibHbix fleKOHrecxanxoB (Hac|)TH3HHa, canopHHa, KCHMejiHHa H x. fl.). B pesyntxaxe Hepauno-
I. BocnannxenbHbie 3a6oneBaHMfl nonocTM Hoca
117
najibHoro JieneHHa pasBHBaexca «na(J)XH3HHOBaa» saBHCHMOCXb, npn Koxopoii
6ojibHOMy ffjia yjiynmeHHa HOCOBOFO abixanna xpe6yexca eace^HCBHoe Hcno;ib3oBaHHe HHxpanaaajibHbix fleKonrecxanxoB BO Bce GojibiiieH ^ose (<J)M3H4ecKaa saBHCHMOCTb). B KOHCHHOM HXOre HH CMCHa KanCJlb, HH yBCUHHCHHe flOSbl JIBKapCX-
BCHHHX npenapaxoB K OTHxenbHOMy ynyHuieHHio HOCOBOFO flbixaHna ne npHBoflax. OocxeneHHO pasBHBaroxca no6oHHbie 3(J)(})eKXbi npHMenaeMbix cpe^cxB. OH3HHecKaa saBHCHMocxb HHor^a nepexoflHX B saBHCHMOCXb «HCHXHHecKyio», Koraa
HocoBoe flbixaHHe pe3KO yxyauiaexca npn MHCJIH, HXO no/i pyKOH Hex cocyaocyMCHBaioiuHX Kane^b. TaK5Ke 6ojibHbix GecnoKoax ranocMHa, rojiOBHaa 6o:ib, 6bicxpaa yxoMJiaeMocxb, HHor^a — sanoHceHHOcxb B yiuax, yxy/juieHHe naMaxH, nepeflKO pasBHBaexca saKpuxaa rnycaBocxb. O^naKO ^aHHoe saGoJiefiaHne HC BHsbisaex SHaHHxejibHoro napymeHHa o6mero cocxoanna, H 6o;ibHbie npoflojmaiox
BecxH aKTHBHHH o6pas WH3HH, nosxoiviy nocxoaHHbiK ^HCKOM(J)opx H jieKapcxBCHHaa SaBHCHMOCXb BCflyX K paSBHXHK) HeBpO3OHOflo6HbIX COCXOaHHH.
IlpH PHHOCKOHHH cpasy Spocaexcs B rjiasa yBeJiHHCHHe pasMepa HHXCHHX HOCOBHX paKOBHH. Ilpo6a aneMHsauHH nojioacaxejibHa. CjiHsncxaa noca sacxoiiHO
rnnepeMHpOBaHa, HHor^a qsex ee HepaBHOMepen, H Ha o6meM «CHHIOUIHOM» (J)oHC BH^Heroxca Gojiee Sjie^Hbie CHSHC naxna (naxna BoaneKa).
Jlenenue. B neneHHii BasoMoxopnoro pHHHxa MOHCHO Bbi^ejinxb cjie/jyioiUHe
HanpasjieHHa:
• JieneHHe HMCJomnxca cepaeHHO-cocyflHCXbix, HCBpoJiorHHCCKHX, SHJIOKPHHHHX 3a6ojieBaHHH;
• BOCCxanoBJieHHe HopMajibHOH apxHxeKXOHHKH nojiocxH Hoca;
• ceaaxHBHaa xepanna;
•
CHH5KCHHe FHneppeaKXHBHOCXH CJ1H3HCXOH HOCOBHX paKOBHH;
• xnpyprHHecKoe jieneHHe.
'
CpeflcxBa jvin KOHcepBaxHBHoro neneHHa BasoMoxopnoro pHHHxa npaKXHneCKH xaKHe nee, K3K H jjjin jieHCHHa Hos/iHeH (J)a3H ajxiieprHHecKoro pHHHxa H
6poHXHajibHOH acxMbi, Kor/ja y 6ojibHbix ccj)opMHpoBajiacb rnneppeaKXHBHOcxb
SpOHXHajibHoro aepesa H CJIHSHCXOH Hoca. HHHMH cjiosaMH nos^naa 4>a3a auneprHHecKoro pHHHxa Bcer^a HMCCX BasoMOxopHHH KOMHOHCHX. IIocKOJibKy
3XHOJiorna BasoMoxopnoro H anjieprHHecKoro pHHHxa pasuHHHa, a naxorenes BO
MHoroM cxo», MHOFHC oxopHHOJiapHHronorH H ajuiepronorH paccMaxpHBaiox BasoMoxopHHH PHHHX KaK oflHy H3 4>opM anjieprHHecKoro pHHHxa. fljix yMeHbmeHHa peaKTHBHOCXH CJ1H3HCXOH HOCOBHX paKOBHH HCHOJlbSyiOX CHCXCMHbie 6J1OK3-
xopn Hi-peuenxopoB rncxaMHHa Bxoporo H xpextero noKonenHH (icnapHXHH, noMHJian, xeji<J)acx, spnyc), MeM6paHocxa6HHH3axopbi xyHHwx KJICXOK (KCXOXH^CH),
a xao<e HHxpaHasanbHbie xonHnecKHe KopxHRocxepoH^H (HasoneKC, 4>jiHKcoHase, anb/ieuHH). XnpyprHHecKoe JieneHHe ncnojibsyexca /uia AecxpyKUHH no^cjiH3HCTHX BCHO3HHX CHJieXeHHH HH5KHHX HOCOBHX paKOBHH, MTo6bI H3 HX MCCXC
ciJiopMHpOBajica py6eL(. B 3XOM cnynae o6i>eM HOCOBHX paKOBHH coKpamaexca H
HC npoHcxoanx sna^HxejibHoro HSMeneHHa HX o6teM3. BonbHHM nposojiax
118
Tewa VII. SAEOHEBAHUflHOCA H OKOJIOHOCOBblX HA3YX
cjiH3HCxyio yjibxpajByKOByio jjesHHxerpauHio HH>KHHX Hocosbix paKOBHH Ha annapaxe «JIOPA ^OH» HUH no;jcjiH3HCxyio BasoxoMHK) HHJKHHX HocoBbix paKOBHH. 3xH onepau,HH MO>KHO npoBOJjHXb Kan no/i MCCXHOH HHCpmibxpaHHOHHOH
anecxesHeH, xaK H noa oGmHM o6e36ojiHBaHHCM. B nocjieonepau,HOHHOM nepHOae B xeneHHe 6-lOziHeH ocymecxBJiaiox yxozi sa nonocxbio noca
MH cnpeaMH («CajiHH», «AKBa MapHC» H x. a.) win MacjWHbiMH KaruiaMH
nepcHKa, Ksjipa, KaruiH «IlHHOcoji»), 3a sxox nepHoa HOCOBOC /jbixanHe CXOHKO
yjiyniiiaexca, npHMeneHHa cocy/jocyacHBaiomHX Kanejib He xpeSyexca.
CCJIH 3XHOJiorHH6CKHe BaKxopbl, Bbi3BaBiUHe BasoMOxopHbifi PHHHX HC
poBaHbi, xo BCC CHMHXOMH 3a6oneBaHHa nocxeneHHO B03Bpamaioxca ro-sa HSMBHCHHa XOHyCa CXCHOK HenOBpOKfleHHblX yHaCXKOB COCyflOB. B CBaSH C SXHM 3(J>-
4>CKX XHpyprHHCCKoro neneHHa name Bcero BpeMennbiH.
PHHHT (ajiJieprHHecKafl pHHOCHHyconaxHa)*
PHHHX — 3x0 3a6oneBaHHe HOJIOCXH noca, BbisbiaaeMoe anjieprenaMH H xapaKxepH3yiomeeca IgE-saBHCHMbiM BOcnaneHHCM CHHSHCXOH
O6OJIOHKH HOCOBOH HOJIOCXH.
Bo BCC MHpe ajuieprH^ecKHM PHHHXOM cxpa^arox 10-25 % HaceJieHHa, npHHCM ero pacnpocxpaHCHHOCxb HOCXOSHHO Bospacxaex. Oco6eHHO Sbicxpo yBenHHHBaexca HHCJIO flexeft, cxpa/jaiomHX ajuieprHHecKMM PHHHXOM. y 45-60 % naUHCHXOB c ajuieprHMecKHM PHHHXOM B nocneayiomeM pasBHBaexca 6poHXHajibHaa
acxMa, a y 50-70 % aexeB c 6poHXHanbHOH acxMOH aHarnocxHpyexca aiuieprHHCCKHH PHHHX. Hacxoe coHCxaHHe anjieprHHCCKoro pHHHxa H 6pOHXHanbHOH acxMbi nocjiy>KHJio ocHOBaHHCM pasBHXHa HayHHoii KonuenuHH <<eflHHaa flbixaxenbnaa cHcxeivia, e^HHoe 3a6ojieBaHHe».
AmreprHa (axonHa) CBasana c roMOHHXoxpoiiHbiMH aHXHxenaMH Knacca IgE. OflnaKO He cueflyex nonaraxb, HXO o/iHoro noBbiuieHHa ypoBHa IgE flocxaxoHHo j\fl%
pa3BHxna axonHH. BbicoKHti ypOBeHb IgE HC rapaHxnpyex nojuiHHOsa HJIH 6poHXHanbHOH acxMbi. HxoSbi pasBHJiacb axonna K BbicoKOMy xmpy IgE AOIDKHO npHCoeflHHHXbca BbicoKoe coflepacaHHe IgE-peuenxopOB B xynnbix KJiexax H 6a30(J)HJiax, a
xaicace neaflCKBaxHO BbicoKaa HyBcxBHxenbHOCXb CJIHSHCXOH noca HJIH KOHCH, jiencHX
H apymx opraHOB-MHUieHCH K rncxaMMHy. y o^Horo SojibHoro Hepe^Ko naxoAax anjieprHHecKHH PHHHX, GponxHanbHyio acxiwy, KOHbioHKXHBHX, KpanHBHHuy.
Do/i fleficxBHeM cxHMyjia xynnaa KnexKa Bbiaenaex Meflnaxopw anjiepTHH
FHCXaMHH,
FCHapHH,
XpHHXaSy,
XeMaXTpaKXaHXbl ^JIH 3O3HHO(j)HJIOB,
MaKpo<})aroB, HCHXpo<J3HJioB. Bbi^eneHHe H naKonjieHHe HX npOHCxo^HX oieHb
6bicxpo, nosxoMy CHMnxoMbi anneprHH pasBHBaioxca MFHOBeHHO nocne KOHxaKxa c ajuieprenoM. Hepes H_i-peuenxopbi rncxaMKH Bbisbisaex OXCK CJIHSHCXOH Hoca H SpoHxocnasM.
Teiwa ocBemeaa B cooTBexcxBHH c MeawyHapoflHoH nporpaMMofi ARIA (allergic
rhinitis and its impact on asthma initiative), paspaSoraHHOH B coxpy^HMHecTBe c BO3,
2001 r.
119
. BocnannTenbHbie 3a6oneBaHMfl no/iocxki Hoca
HHTepMHTTHpyiOIUHH
CHMIIXOMSI:
• MeHee 4 RMSM B ne,aejiK> HUH
• MeHee 4 Herein,
nepcHCTHpyrouiHH
CHMnxoMbi:
• Bojiee 4 ^Hett B He^ejHO HJIH
-i • Bojiee 4 neaejib
JlerKHH
• HapymcHHe cna
• HapymcHHe
COH
• HopMajibHaa
aKXHBHOCXb,
OXJJBIX,
33HaTHa
cnopxoM
• HopMajibHaa npo<J)eccHOHajibnaa aeaxejibHocxb
• OrcyrcxBHe MVHHrejibHbix CHMnxoMOB
aKXHBHOCTH,
H6BO3MO>KHOCTb
cnopxoM, nopMajibHoro
HapymeHHe
CHMnXOMOB
Puc. 22. KjiaccH<J)HKaqHa ajuieprHiecKoro pHHnxa
KnunuKa. HanSoJiee qacxbiMH acajio6aMH y SojibHbix amieprHHecKHM PHHHXOM aBJiaroxca sya noca, npncxynu HHxaHHa, snesanHbie oGnjibKbie cjiHsncxwe
BbiflejieHHa HS Hoca, cjiesoxeneHHe, saxpyjjHeHHe HOCOBOFO flbixaHHa. O6 anjiepFHHCCKOM pHHHXC MO5KHO FOBOpHXb, CCJIH 7JB3 H 6oJI6e CHMHXOMOB npO8BJiaK)XCa
6onee 1-ro Haca na npoxajKeHHH 6ojibuiHHCXBa JJHCH 6ojie3HH. B 3asHCHMOcxH ox
npeo6;iaflaHHa onpejjejienHbix CHMHXOMOB KJiHHHnecKH 6o;ibHbix amieprHHecKHM
PHHHXOM noapasjjejMiox na JJBC rpynnu: «HHxanbmHKH» H «conenbmHKH» (xa62). TlHarHocxHKa ocHOBana na BbiaBJieHHH XHHHHHWX CHMHXOMOB sa6ojie. PHHOcKOHHHecKaa Kapxnna saBHcnx ox cxa^HH ajuieprHHecKoro npouecca,
B cBasH c HCM oxjiHHaexca noJiHMOp4)HOcxbio. TaK, B paHHCH <J>a3e anjieprHHecKoii
y «HHxajibmHKa» BO BpeMa npncxyna cjiHsncxaa noca cxeKJiOBH/jHO
Gjie^Haa, npocj)y3Ho ceKpexnpyex BOAaHHCxyio cjinsb. B nosaHeft chase
anjieprHiecKOH peaKUHH B peMHCCHK) cjiHsncxaa noca yMepenno oxenna, sacxonHO rHnepeMHpOBana, Moryx Ha6jnoflaxbca naxna BoaneKa, B HOJIOCXH noca B MaJIOM KOJiHHecxBe coflepacHxca FHoiiHoe ox^ejiaeMoe. y «conejibuiHKa» 6onee BHpa>KeH OXCK HOCOBWX paKOBHH, UBCX CJIH3HCXOH BapbHpyexca ox 6jieflHOH Jio CHHIOIUHOH, MOHCCX Menaxbca B xeneHHe cyxoK. HasanbHbiH ceKpex HOCHX CJIHSHcxbift, CJiH3HCXo-rHOHHHH xapaKxep, KOJIHHCCXBO ero yMepeHHoe.
fluazHocmuKa. OCHOBHOC BHHMaHne B #HarHocxHKe yaejiaexca HajiniHio XHnHHHbix ajuieprHHecKHX CHMHXOMOB B anaMHCse, HO cjiejryex noMHHXb, HXO xapaKxepHbie ajuieprnqecKHe CHMOXOMH HC Bcer;ja HMCIOX ajmeprnHecKyio npnpo-
120
TeMa VII. 3AEOnEBAHMflHOCA H OKOJIOHOCOBblX HA3YX
Ay. Run AHarnocxHKH IgE-onocpeAcmaHHbix peaKUHH neMefljieHHoro xnna HCnoubsyiox KO5KHbie npo6w. OnpeaejieHHe yposHH ajuiepreH-cneuH<J)HHecKHX IgE
B CblBOpOXKC KpOBH HO flHarHOCXHHCCKOH SHa^HMOCXH COHOCXaEHMO C KTOKHblMH
I. Bocnannxe/ibHbie 3a6oneB3HMpi nonocTM Hoca
121
iaiox HHipaHasajibHbie KopxHKOcxepoHflbi B BHAC cnpeeB
(DjiHKCOHase, HasoHCKc), Kypc JieneHHa fljmxcH ox 1 Mecau,a H 6o;iee. PaspaGoxana
cxyneHHaxaa cxeMa MeflHKaMeHxosHoro jieieHHH amieprHHecKoro pHHHxa (pnc. 23).
npo6aMH. HasanbHbie npOBOKauHOHHbie npo6bi c amiepreHaMH B KJIKHKHCCKOH
npaKXHKe HcnojibsyioTCH Bee pe>Ke, xoxa HX aKxyajibnocxb coxpanaexca npn AHarnocxHKe npo(J)eccHOHantHoro pHHHxa.
flHarHOCTHica anneprHHecKoro puuHra
VcrpaHeHHe KOHTairra c anjieprenoM
Ta6jiuifa 2
KjimiiriecKasi oueiiKa ajuieprHHCCKoro pumira
CHMHTOM
HnxaHHe
Pmiopea
«MHxajitruHKH»
H «CMOpKajlbIHHKH»
«ConejibiuHKH»
HHrepMHTTHpyiomHe CHMnroMU
,
I
I
JlencHe
HesHaHHiejibHO
HJIH oTcyrcTByer
BoflHHHCTbie BbweneHHa nepea- Fycxbie Bbi^ejieHHa npeHMyme-
CpeflHe-Tawejiue/
Tawenbie
OcoGeHHO npHcrynaMH
HH6 H 33flHHe
CTB6HHO SaAHHC
OxcyTCTByeT
Hineerca
3ya B Hocy
HasaiibHaa oScrpyK- HenocToaHHaa
^lacTO H CHjibHO BbipaaceHnaa
qiis
flHeBHOH pHTM
YxyfliueHHe cocroflHHa AHCM H PaBHOMepHHH BO3MO>KHO yxyflIIieHHe HOHbK)
yjiynuieHHe HOHBK)
KOHblOHKTHBHT
HaGnioaaexca nacjo
Jlevenue ajineprHnecKoro pHHHxa BKJiioHaex B ce6a cjiejryjomHe Mepw:
• ycxpaneHHe KonxaKxa c ajuieprenoM;
xepanna;
H i-6jioKarop
• HirrpaHasajibHbiH
Hi-fijioKaxop
H/HJIH jjeKOHrecxaHT
I
nepcHCTHpyiomire CHMIITOMU
I
JlerKHe
FIcpopajibHbiH H]-6jiOKaxop
• HHrpanasajibKbie
KOpTHKOCTCpOHflbl
H/HJIH aeKOHreciaHT
• HHipaHaaajibHbiii KOpTHKOcrepOHfl
• KpOMOH
OScJie^osaTb SojibHoro
nepes 2-4
IIpw nepCHCTHpyromeM PHHHTC
o6cjie^OBaTb 6oJibHoro
lepes 2—4 HC^CJIH
V
IlpH He34>4>CKTHBHOCTH nepeHTH
Ha ojiny cryneHb BBepx
FIpH yjiyqiiieHHH npoaojracHTb
neieaae B xeieHHe 1 weoma
• XHpypraHecKoe neneHHe.
B JieneHHH ajiJieprHHecKoro pHHHxa Hcnojibayrox CHCXCMHUC aHXHrncxaMHHHbie cpeacxBa, npeflnoHXHxejibHO Bxoporo H xpexbero noKOJieHHa (KjiapnxHH,
JIexH3CH, Tencjmcx, 3pnyc), nocKOJibKy OHH HMCIOX HaHJiyHinee conexaHHe 3(j)4)CKXHBHOCXH H 6e3OnaCHOCXH, BO3MO»CCH HX AJIHXCJlbHblH HpHCM B XCHCHHC HC-
cKoubKHx MCCSHCB 6e3 pasBHXHH Ho6oiHbix stJj^cKxoB. 3xH npenapaxbi Gbicxpo
(B xeneHHe naca) yMenbuiaiox pHHOpeio, syfl noca, ruasHbie CHMnxoMbl. J\nnxejibHOCXb xepaneBXHHCCKoro ^encxBHa nocne npneMa 1 xagjiexKH cocxasnaex
24 naca, B CBHSH c HCM OHH yao6Hbi B HcnojibSOBaHHH. KypcaMH Hasnanaiox HHxpanasajibKbie anxHrHcxaMHHHbie npenapaxw (xeji(j)acx, KjiapHXHH, jiOMHJiaH,
apnyc H x. A.), HHXpaHasanbHbie KpOMOHbi (cnpefi JloMysoji, KannH KpoMoriiHKaxa), KopoxKHMH KypcaMH B JieneHHH ncnojibsyrox opanbHbie (coflep^cauiHe HCCBA03(J)e4pHH, <J)eHHJi34)pHH) fleKOHrecxaHTbi HJIH HHXpaHasanbHbie aeKOHrecxaHXbi,
coAep>KaiUHe B CBOCM cocxase KopxHKOCTepOHflbi (A(J)pHH, BnGpouHH H x. A.).
flflu JICHCHHS nepcHCXHpyiomero amieprHHecKoro pHHHxa, a xaoce ana JieneHHH
cpeAHe-xa)KejioH H xoacejiOH (popM HHxepMHTXHpyiomero pHHHxa 6onbHbiM Hasna-
— yBejiHHHTb ao3y nasajibHoro KopTHKocrepoHaa
— npH pHHopee aoSasHTb HnpaxpoKarop
— npH oScxpyKUHH flo6aBHTb neKOH-
Her 3<j>4>eKia
i
uHH xHpypra
Puc. 23. CxyneHHaxaa cxeMa MeaHKaMCHXOSHoro JieneHHa
anjieprHHecKoro pHHHxa
122
TeMa VII. 3A5OnEBAHMflHOCA U OKOJlOHOCOBblX HA3YX
<J>H6po3nbiH xpOHHiecKHH rnneprpo(J)HMecKHH PHHHT (HCTHKHMH ranepTpo(j)HHecKHH PHHHT) asjiaeTca npoaBjieHHCM HCTHHHOH rHnepTpo<})HH TKaneH
HOCOBWX paKOBHH, KOTOpaa name HOCHT OHaroBbiH, peace — ;iH<j)<J)y3HbiH xapaKTep pacnpocTpaneHHa. B saBHCHMocTH OT naTOJioroaHaTOMHHecKHx
onaroBbiH (J>H6po3HbiH rHnepTpo(J>HHecKHH PHHHT noflpasflejiaioT na
, <J)H6po3Hyio, nanmuiOMaTosHyK), THnepBacKyjiapHyjo, KOCTHyio,
4>opMbi, a ^HCJxjjysHbiH ™nepTpo(J>HHecKHH PHHHT — na KOCTHyio, ranepBacKyjwpHyio, KOMSnHHpOBaHHyio (JjopMti. OnaroBbie HSMeneHHa name JioKajiH3yioTca Ha nepeflHCM HJIH sa^HCM KOHuax HHJKHHX HJIH cpeannx HOCOBHX
paKOBHH, HHOraa
B KaKOH-TO OflHOH o6jI3CTH HOJ1OCTH HOC3. OCHOBHaa 5KaJIo6a
y SojibHbix npH HCTHHHOH rHnepTpo<J)HH HOCOBHX paKOBHH — CTOHKoe HapyuieHHC HocoBoro flbixaHHa, OTMenaeTca OTcyrcTBHe 34><J)eKTa OT npHMCHCHHa HHTpanasajibHbixflCKOHrecTaHTOB.BojibHtie xpOHHHCCKHM rHnepTpo(})HHecKHM pnHHTOM CKJIOHHbl K paSBHTHK) K3Tapa BCpXHHX flblXaTCJIbHblX nyTCH. V HHX HCpefl-
KO Ha6niOflaK)Tca BbmejieHHa H3 Hoca, HTO asjiaeTca cjieflCTBHCM sacTOHHbix as^CHHH B CJIH3HCTOH oGoHOHKC HOC3, CHHMCCHO o6OHaHHC. IlpH rHHepTpO(J)HH 33flHHX KOHUOB HH>KHHX HOCOBblX paKOBHH MOSCCT BO3HHKHyTb HSpyiUCHHe CJiyX3.
IlpH PHHOCKOHHH BbiaBJweTca orpaHHHCHHoe HJIH aH4«})y3Hoe yBejiHHCHHe paaMCpa HOCOBblX paKOBHH, npo63 aHCMHSaUHH OTpHUaTCJIbHafl.
Jlenenue HCTHHHOH rHnepTpo<J)HH HOCOBHX paKOBHH TOJibKO XHpyprnHecKoe.
BoJibHbiM npoBo^aT noflCJiHSHCTyio nacTHHHyio HJIH nojinyio KOHXOTOMHKX Dpn
Heo6xoflHMocTH ee flonoJiHaiOT JiaTeponosHUHeH HOCOBOH paKOBHHbl. B cjrynae
HCTHHHOH KOCTHOH rHHepTpO({)HH npOBOflHTb TOTajIbHyiO KOHXOTOMHK) HOCOBOH
paKOBHHbl HC peKOMeazrycTCfl, nocKOJibicy BbipaaceHHoe H3MeHCHHe apxHTCKTOHHKH HOJIOCTH HOC3 B AaJIbHCHIIieM npHBO^HT K 3TpO<J)HHeCKOMy pHHHTy, HOCTOaHHOMy o6p330BaHHK) TOHKHX KOpOK H3 CJIH3HCTOH HOJIOCTH HOC3, 3aTpyflH3K)IUHX HOCOBOC flblXaHHC, BbBblBaiOIUHX 3yfl B HOCy.
AxpocjiHiecKHH PHHHT. O6menpHHaTO BbweJWTb ^se <})opMbi aTpo^HHCCKOro pHHHTa: npocTOH aTpo<})HHecKHH PHHHT H oseny.
HpocTOH 3Tpo4>HHccKHH PHHHT aBJweTca npoaBJieHHeM saBcpuiaiomero 3Tana OTHTejibHoro xpOHHnecKoro BocnajiHTejibHoro npouecca B HOJIOCTH noca, no3TOMy name Ha6jiK)flaeTca y no»Hjibix jro/jen. O^HSKO cnoco6cTBOBaTb aipo^HH
CJIH3HCTOH Hoca Moiyr onepaTHBHwe BMcmaTeJibCTBa, noBjieKEiHe napymeHHe
apxHTCKTOHHKH HOJiocTH Hoca, npo(J)eccHOHajibHbie BpeAHOCTH (pa6oTa B cyxHx,
acapKHx uexax, sanbuienHbix noiwemeHHax), ranoBHTaMHHOSbi, HapyuieHna 06M6H3 BCmCCTB. Mop(j)OJIOrHHeCKHe HSMCHCHHa HpOHCXOflaT TOJibKO B CJIH3HCTOH
o6ojiOHKe nojiocTH Hoca. CjiH3HCTaa CTaHOBHTca cyxon, Ha nefi npaKranecKH OTcyrcTByex cjinsb. OSpaayromaaca B ManoM KOJIHHCCTBC cjiH3b rycTaa, 6wcTpo sacbixaer, o6pasya KOPKH. MepqaTejibHbiH anHTCJiHH MCTannasHpyeTca B MHOFOCJIOHHblH HJIOCKHH. KOJIHHCCTBO 60KaJIOBHflHbIX KJICTOK 3H3HHTejIbHO yMCHbUia-
exca. CiiHSHCTbie acejiesbi jierenepaTHBHo HSMCHeHbi. BoKpyr CJIHSHCTHX >Kejie3
H36jnoflaioTca eocnajiHTejibHbie HHijjHJibTpaTbi. HsMeneHHaa cjinsncTaa Jierao
I. BocnannTenbHbie 3a6ojieeaHMfl nonocTM Hoca
P3HHM3, HOSTOMy npH pHHOCKOHHH HCpejIKO MO3KHO yBHflCTb CyKpOBHHHblC
123
KOp-
KH. FIpH HHTCHCHBHOM BbICMapKHB3HHH MOiyT BO3HHK3Tb HOCOBHC KpOBOTeHC-
HHa. IlocKOJIbKy ecTecTBCHHbie samHTHbie MexaHH3Mbi cnnsHCTOH HOC3 yrpsneHH, na arpocJmHHOH CJIHSHCTOH scer^a KOJiOHH3Hpyerca narareHHaa MHKpo(J)Jiopa, nojmepscHBaa rHOHHbifi BOcnaJiHTenbHbiH npoqecc. Aipo^Ha MOMCCT saxparHB3Tb OTflCJIbHbie o6jI3CTH HOJIOCTH HOC3, HTO HaiUC H36jIK)fl3eTCa HpH 3TpO(})HHeCKOM pHHHTC HOCJIC OHCpaTHBHUX BMeUiaTCJIbCTB. ^H(J)(J)y3Hbie (J)OpMbI X3p3KTCpHbl JXIM 6oJIbHbIX nOaCHJIOrO B03p3CT3. IlpH aH(})4)y3HOM 3TpO<})HHeCKOM pHHH-
xe Moacer pasBHTbca rnnocMiw.
Jleueuue HanpasjieHO HE noBbimeHHe (no;mep5KaHHe) ceKpeTOpHOH EKTHBHOCTH CJIH3HCTHX XCCJICS, yflaJICHHe KOpOK, yBJiaXCHCHHe HOBCpXHOCTH CJIH3HCTOH
o6ojiOHKH. PeKOMeHflyioT npHMeHCHHe BHyrpb npenapaTOB fiofla, cnocoScTByioIUHX noBbimeHHK) aKTHBHOCTH cJiH3HCTbix xcejics (3 % pacTBOp HOflHiia Kajina no
15 Kanejib 3 pasa B aenb B TeneHHe Mecaiia). HasnanaioT BHTaMHHW A, E, D,
rpynnw B, 6HoreHHbie cTHMyjiaropbi (ajioa, OnBC, aKcrpajcr njiaueHTbi, ryMHsoJib,
rjuonaT). BnoreHHwe CTHMyjiaropw — ajios, OnBC — MOHCHO Hcnojib3OBaTb H MeCTHO B BHflC HHtCKmlH B HOCOBblC paKOBHHbl. PeiyjIHpHO HpOBOflHTCa yflajICHHC
KOPOK, GojibHHM peKOMCHflyioT eaceflHCBHO saKanbmaTb B HOC Macjianbie pacrBOpbi
BHT3MHHOB A, E HJIH HepCHKOBOC, OJIHBKOBO6, HOaCOJIHCHHOe M3CJI3, KOTOpblC HH-
TaroT H ysjiaacHaioT cjiHSHcryio o6ojiOHKy, pasMarnaioT oGpasyiomHeca KOPOHKH H
cnocoScTByiOT HX caMonpoHSBOJibHOMy yaajieHHio. flfls yxoaa 3a nojiocTbio noca
peKOMCHflyioT HcnoJib30BaHHe cpeflCTB THna «CaJiHH», «AKBa Mapnc», «MypHHa
HJIIOC», KOTOpbie npeflCTasjiaiOT coGoii HSO- HJIH ranoTOHHHecKHe pacTaopbi H3xpna xjiopH^s H coflepxcaT pasjiHHHwe M3Kpo- H MHiqxojieMeHTbi.
O3CII3 (3JIOBOHHHH H3CMOpK)
3muojiozua. 3a6ojieBaHHe HSBCCTHO c anTHHHbix BpeMCH. KjiHHHnecKoe OHHcaHHe oseHbi BCTpenaerca B xpyflax FHnnoKpaTa, LJejibca, FaneHa, oanaKO 06
3THOJIOFHH 3a6ojI6BaHHa flO HaCTOaUICrO MOMCHT3 e^HHOH TOHKH 3peHH» HC Cy-
mecTByeT. C KOHua XIX BCKa HSJIOXCCHW ^BC TeopHH STHOJIOFHH OSCHH — HH<J)eKUHOHHaa H HCHH^eKUHOHHaa, K3»yiaa HS Koxopbix oGocHOBana H HMCCT CBOHX CTOpOHHHKOB. GrOpOHHHKH HHcJjeKHHOHHOH TCOpHH CHHT3IOT, HTO FJiaBHaa
pOJIb B p33BHTHH O36HbI HpHHaflJieHCHT GaKTCpHH Klebsiclla OZaenaC H3 CCMCHCTBa
3HTepo6aKTepHH. Cnoco6cTByiOT nporpeccHpoBaHHio OSCHH HeHpo-SH^oKpHHHbie H3pyuieHHa, KJiHMaTHHecKHe H couHajibHbie 4>aKTopbi. KpoMe KJieScHeji y
SoJIbHblX 036HOH H3 HOJIOCTH HOC3 BblCCBaiOT KOpHHe6aKTCpHH, npOTCH. OTMCHCHO, HTO KOJIHHCCTBO KOKKOBOH MHKpO(J)JIOpbI 3HaHHTCJIbHO MCHblUe, HCM H3
HOp-
M3JIbHOH CJIH3HCTOH o6oJIOHKC HOJIOCTH HOC3. CHHT3CTCa, HTO ,ZJH36aKTepH03 CJIH-
3HCTOH o6ojiOHKH nozwepacHBaeT BOcnajiHTejibHbiH npouecc.
CTOpOHHHKH HeHH(J)eKI];HOHHOH TCOpHH nepBOHpHHHHOH 3a60JI6BaHHa CHHTaiOT
HeHpOflHCTpO(J)HHeCKHe HSMCHCHHa CJIH3HCTOH o6oJIOHKH H KOCTHOFO CKejICTa HOJIOC-
TH Hoca, KOTOpwe cosaaiOT ycjioBHa, noflxoAamne flJia KOJiOHHsaiiHH B nojiocTH Hoca
i, KopHHe6aKrepHH H npoTea H HenpHCMJieMbie jwa pasMHOHceroia KOKKOBOH
124
Teiwa VII. 3AEOflEBAHHflHOCA H OKOJlOHOCOBblX HA3VX
(Juiopbi. PesyribTaTOM ^HcrpO(J)HHecKHx HSMeneHHH H MCHSHeflearejibHOCTH GaicrepHH
aBJiaerca paapyuieHHe TKaneBbix 6enKOB c BbmeneHHeM Himona, cKaTona, cepoBOflopofla, HTO oSecneHHBaer KpafiHe anoBOHHbiH sanax HS noca.
KnuHum. BojibHbie osenoH xcanyioTca Ha o6pa3OB3HHe KopOK B HOJIOCTH HOca, OTcyrcTBHe o6onaHHa, aaipyaHCHHe HOCOBOTO flbixanna. HeHpo-flHCTpo(J)HHCCKHC HSMCHCHHa o6oHaTeJlbHHX peueHTOpOB npHBOaaT K paSBHTHIO 3CCCHUH-
ajibHofi aHOCMHH. AHOCMJM 6:iOKHpyeT BOcnpHarae sanaxa H3 noca caMHM 6o;ibHbiM, HTO nopoayjaeT GwTOBbie H counajibHbie npo6jieMbi. EoJibHOH He MOHCCT
a/jeKBaxHo oueHHTb CBOC cocToaHHe, OTHOiueHHe K ce6e OKpyxcaiomHX H He BCCrfla noHHMaex Heo6xoflHMOCTb jieneHHa. 3anax nsaaiOT MHoroHHCjieHHbie pasjiaraioiUHeca KOPKH, noKpHBaromHe npaKTHHecKH BCIO nosepxHocTb HOJIOCTH noca.
C KopKaMH 6ojibHbie CBasbisaioT HapymeHHa HOCOBOFO flbixaHHa. OflHaico npn
PHHOCKOOHH MOJKHO yBHfleTb orpoMHbie SHaiomne HOCOBbie xoflbi, npaKTHHecKH
nonHoe OTcyrcTBHe HOCOBHX paKOBHH, nep4)opauHio B xpamesoH, KOCTHOH nacTax HOCOBOH neperopo^KH. SaTpyaneHHe HOCOBOTO flbixanna B 6ojibiueH CTCHCHH
CBaaaHo c paapyuieHHCM orpOMHoro Heftpo-peuenTopHoro nona CJIHSHCTOH 060JIOHKH nOJIOCTH HOC3 H HOpMaJlbHOH apXHTCKTOHHKH HOJIOCTH HOC3. B CBaSH C
H3MeHCHHaMH CJIH3HCTOH oSoJIOHKH yrpaHHB3K)TCa HepBHO-pe^JieKTOpHbie CBa3H
nojiocTH noes c flpyTHMH opraHaMH H CHCTCM3MH opraHHSMa, HTO HapyuiaeT perynaijHio flbixaTenbHoro airra B ijejiOM. PaspyineHHC crpyiaypbi HOCOBOFO KnanaH3 — nepBHHHoro peryuaTOpa nocTynaroujero BO3ayiuHoro noTOKa — npHBOflHT
K OTCyrcTBHK) peryjiaqHH HOCOBOTO conpOTHBJieHHa, TO ecTb peryjiauHH o6t.eMa,
CKOPOCTH H xapsKrepa BosayuiHoro noTOKa B OOJIOCTH noca.
JJevCHUe
03CHH JIO CHX nop
OCTaCTCa npCHMymeCTBCHHO CHMnTOM3THHC-
CKHM, HTO eme pas yicasbiBaeT na TO, HTO 3THOJiorHHecKHH 4>aRTop ue
KypcaMH CHCTCMH3a aHTuSaKTepHajibHaa Tepanaa (Terpaq
I noKOJieHHa), HO ona ne peiuaeT npo6;ieMbi aHc6aKTepH03a
nonocTH Hoca, 6ojiee TOFO, nacToe yBJieneHHe CHCTCMHbiMH aH™6aKTepHajibHbiMH npenapaxaMH cnoco6cTByeT pasBHraio flHcGaicrepHOsa KHiiieHHHKa. OCHOBHbie jiene6Hbie MeponpnaTHa HanpaajieHbi Ha yxoA 33 noJiocTbro HOC3. Bonbiiioe
BHHMaHHe yuenaeTca yAajieHHio KOPOK HS noca. FIojiocTb noca npoMbisaiOT 1 %
pacTBOpoM nepeKHCH Boaopoas, 2 % pacTBopoiw coaw, 0,1 % pacTBOpoM nepManraHaT3 K3JiHa, 1 % pacraopOMflHOKCHflHHa.Jinx pa3MarneHna KopoK B noJiocTb Hoca BBOflaTca xypynflbi c HMMOSHMasofi, HOfl-raHuepHHOM, Masbio BHIIIHeBCKoro, npoBoaaTca HHrajrauHH c (JjepMCHTaMH — TPHHCHHOM, KOJuiareHasoii,
. CymecTByiOT xnpyprHHecKHe cnoco6bi KoppeKqHH HOCOBOFO
npH oseHe. /lanHbie onepauHH HanpaBJienbi na cyxenHe npocscTa noJIOCTH Hoca c noMombio TpaHcnuaHTaTOB H3 JiaBcana, Kanpona, aKpHjiosoH nnaCTMaccbi. TpancnjiaHTaTbi nepeflKO oiropraiOTca, no3TOMy aaHHbie XHpyprHHeCKHC BMemaxejibCTBa HC nauuiH uiHpoKoro npHMCHCHHa. ripeflJiOMceHbi onepauHH
nacTHHHoro mm HOJIHOFO sanpHTHa OOJIOCTH noca. flnx yjiynineHHa KKHHHHCCKOH KapTHHbi oscHbi HcnojibsyiOT onepauHK) T. BHTTMaaica (Wittmaak) — nepe-
IV. BocnannTenbHbie 3a6oneBaHnn OKO/iOHOCOBbix naayx
125
npOTOKa OKOJioyuiHOH CHIOHHOH acejiesbi B BepxHeHeJuocrayio nasyxy.
BepxHenejHOCTHyio nasyxy BCKpusaioT nepes nepeflHjoro CTCHKy. Ha BHyrpeHHCH nOBCpXHOCTH mCKH BHKpaHBaiOT JIOCKyT C BblBO^HblM HpOTOKOM OKOJIOyiU-
HOH CJIIOHOH »cejie3bi, KOTOpwii nepecaacHBaioT B BepxHeneJiiocTHyio nasyxy. Pany B npeziflBepHH OOJIOCTH pTa sauiHBaiOT. Bbmejiaromaaca cjiiona nocToaHHO
cJiH3HCTyio o6o;iOHKy HOCOBOH HOJIOCTH.
IV. BOCnAJlHTEJlbHblE 3A5OJ1EBAHWI
OKOJlOHOCOBblX HA3YX
BocnajiHTCJibHbie saGojiesaHHa npiwaTOHHbix nasyx noca (CHHycHTbl) OTHOCaTCH K OCHOBHbIM HpoGjICMaM OTOpHHOJiapHHFOJIOFHH. Ho paCHCTHblM fl3H-
HbiM U,KB MeflHUHHCKoro ueHTpa ynpaBJieHna aejiaMH npesH^eHTa, B POCCHH
exceroflHO nepenocaT CHHycHT 10 MJIH HejioaeK. O KOJioccsjibHbix (JmnancoBbix
33TpaT3X H3 JieHCHHC CHHyCHTa FOBOpaT BO BCCM MHpe. YHHTbIB3a MOp4>O-(J>HSHOJIOFHHeCKOe CflHHCTBO CJIH3HCTOH HOJIOCTH HOC3 H napaH33aJIbHHX CHHyCOB,
GoJibiUHHCTBO OTOpHHOJiapHHFOJioroB HasbiBaeT BOcnancHHe npHflaTOHHbix na3yx
HOC3 pHHOCHHyHTaMH,
nOflHCpKHBaa
HCpaSpblBHOCTb naTOJIOFHHeCKOFO
npouecca.
PHHOCHHyCHT
BOCnaJICHHe CJIH3HCTOH o6oJIOHKH HOC3 H npHfl3TOHHbIX
nasyx npaKTHHecKH Bcer^a asnaerca cjieflCTBHCM napyuieHHa aapsqHH OKOHOHOCOBblX H33yX, 33CTOS H HH(})HUHpOB3HHa B HHX CCKpeT3. EAHHOH oGmenpHHSTOH B
np3KTHH6CKOH BpaHe6HOH fleaTCJIbHOCTH KJiaCCH(})HKaUHH HapaHasaJIbHblX CHHyCHTOB, COHBTaiOmeH B Cc6e naTOJIOFO-aHaTOMHHeCRHC H KJIHHHHCCKHe HSMCHC-
HHa, HCT.
Ha OCHOBC naToreHeTHHecKHx H3MeHCHHH GasHpyerca KJiaccH<J)HK3UHa fl. H. TspacoB3, npewioaceHH3a B 1978 r. Ha IV BcepoccHHCKOM ctesae oTopHHOJiapHnro^OFOB. COFJI3CHO 3TOH KJISCCH^HKaUHH, CHHycHTbl HOflp33^ejiaiOT Ha OCTpbie H
XpOKHHCCKHC. CpCflH OCTpblX CHHyCHTOB p33JIHH3IOT: CCpOSHblC, K3TapajIbHbie,
FHOHHbie, 4)H6pHH03HO-FHOHHbie, FeMOpp3FHHeCKHe (})OpMbI. XpOHHHCCKHe CHHyCHTbl 00 3KTHBHOCTH BOCnaJIHTeJIbHOFO npOUCCCa flCJiaTCa H3 HOpMeprHHCCKHC H
FHnepeprHHecKHe. Ilo MOp4)OJiorHHecKHM HSMencHHaM BbiflenaioT ceposHbie, KaTapajibHbie, raoHHbie, nceBflorHOHHbie, npHCTeHOHHO-rHnepmiacTHHecKHe, noJIHHOSHbie, 3TpO(J)HHeCKHe (J)OpMbI.
IIpHBefleHHaa KJiaccH(})HK3UHa 3KTyanbHa wia npoBeflCHHa Haynnbix nccjieaoB3HHH, HO TpyflHOnpHMCKHMa B KJIHHHKC B BHfly CBOCH FpOMO3flKOCTH. fljia np3K-
THHecKHX BpaneH 6ojiee yao6Hbi B paGoTe KJiaccH4)HKaimH CHHyHTOB, nanpaBjiaiomHe TaKTHKy JieneHHa, xoTa H B MCHbiueH Mepe oTo6pa»aiomHe naTOJioraHeCKHH npouecc. Ilo B. C. npeoGpaacencKOMy, CHHycHTbl aejiarca na KaTapajibHbie,
rHOHHbie, nojiHnosHbie, ceposHbie, xojiecreaTOMHbie, aTpo<j)HHecKHe, CMemaHHbie
4>opMbi. HaroryHiuHM o6pasoM noMoraer onpeaeJiHTbca c T3KTHKOH jieneHHa cnny-
126
Tewa VII. SAEOJIEBAHMflHOCA M OKOJIOHOCOBblX
IV.'BocnannTenbHbie 3a6ojieeaHMfl OKOJIOHOCOBUX naayx
CHxa KJiaccH4>HKamw A. C. JIonaTHHa (2000 r.). Corjiacno SXOH KJiaccH(|>HKaiiHH,
no sxHonaxorenesy yfloGno BbwejiHu. cjieayiomHe <J>opMbi pHHocHHycnxa:
— EHpycHbifi;
63KXepH3JIbHbIH (HerOCnHX3JIbHbIH, rOCnHXajIbHHH, OflOHXOreHHHH,
H3
4>OHC HMMyHOae(|)HUHX3);
Ilo npeHMymecxBCHHOH JioKaJinsauHH BocnajiHxejibHbix HSMeaeHHH cpe,n;H
pHHOCHHyCHXOB pa3JIHH3K)X rSHMOpHX, SXMOHflHX, (J>pOHXHX, C(J)eHOHflHX H COH6-
xaHHbie dpopMti nopaaceHHa npimaxoHHbix nasyx noca: reMHCHnycHx — BocnajieHHe Bcex nasyx O^HOH nojiOBHHbi Jinua, napacHHycnx — BocnanenHe oflnoHMCHHUX napHbix nasyx, nojiHCHHycHx — BocnanenHe pasnwx naayx na o6enx
nojiOBHHax JiHua, nancHHycHX — BOcnaneHHe BCCX OKOJIOHOCOBMX nasyx.
OcxpbiB pHHOcaycHx xapsKxepHsyexca cesoHHOCxbio c noBbimeHHCM sa6ojieBaeMOCXH B6CHOH H OCCHblO. IlyCKOBblM MOMCHXOM B p33BHXHH OCXpOFO pHHOCH-
aycHxa Sbisaex BHpycnaa HH<J)eKUH», H B nacxHocxn — pHHOBHpycbi, na flOJiio
Koxopbix npHxoflHxca OKOJIO 80 % saSojieBaHHH BO BpeMa OCCHHHX BcnwiueK. Ha
pCHxreHorpaMMax npH^axoHKbix nasyx noca y 6o;ibHbix OPBH B 90 % cjiynaeB
HaXOflHX OXCK CJIH3HCXOH H 3aCXOH CCKpCXa, X3KHM o6pa3OM, CHHyCHX
XKHHI-
HOC npoasjicHHe OPBH. EnpycHbiH CHHycnx HMeex BbicoKyio xeimeHUHio K caMopaspemeHHio B xeneHHe 2-3 He^enb. IlpHMepHO B 2 % cjiynaes BHpycHbiii CHHycHx npoKJia^bisaex flopory cHHycnxy 6aKxepHajibHOMy. OCHOBHHMH 6aKxepHanbHbiMH BO36yflHxejiaMH ocxporo pHHOcHHycnxa aBJiaioxca: streptococcus
pneumonia (swceBaexca npHMepno B 40 % cjiynaefi 3a6ojieBaHHH), haemophilus
influenza (OKOJIO 35 % cjiynaes 3a6ojieBaHHH B BeceHHHH nepHOfl). Streptococcus
pneumonia OXHOCHXCH K T-nojioxcHxejibKbiM, p-reMOJiHXHiecKHM cxpenxoKOKKaM,
HMCCX OKOJIO 90 cepoxnnoB, Koxopwe, cMenaa O^HH apyroro, npHcyxcxsyiox B
nojiocxH Hoca, HOCOPJIOXKC nejiOBCKa c MOMenxa ero poxcfleHHa. Haemophilus
influenza — F-oxpHuaTejibHaa GaKiepna, 4>aKyjibxaxHBHbiH anaspoS, pesncxeHxna KO MHOFHM aHXHBHoxHKaM. C haemophilus influenza csasbiBaiox passHXHe pnHoreHHbix MCHHurnxoB H cencHca. y flexen sxox MHKpoopraHH3M aBjmerca <J>aKxopOM pHCKa pasBHxna 6pOHXHajibHOH acxMti. Us flpyrHX BosSy^Hxejiefi ocxpbiH
pHHocHHynx BbisbiBaiox: nponne cxpenxoKOKKH — 7 %, aHaspoGw — 7 %,
moraxella cataralis — 3 %, cxa4)HjioKOKKH — 3 % H 4 % — apyraa MHKpo4)Jiopa.
EnpycHbiH H 6aKxepHajibHbiH pHHOCHHycnx oxnocax K BHe6ojn>raiHHbiM CHHycHxaM, ^HaraocxHKa H ne^eHHe Koxopbix npoBOzurrca aivi6yjiaxopHO. I!OMHMO SXOH rpynra>i, cymecxByiox rocraixajibHbie pmiocHHycHXbi, BbissaHHbie naxorenHbiMH urraMMaMH cxaiJjHJiOKOKKa H CHHeraoHHOH nanoHKOH, B XOM HHCJie — HasoKOMHanbHbie (BHnpo/yieHHOH HHxySauHeH y xaacejio6ojn,Hbix) H oflOHXoreHHbie CHHycHXbi
npn BOcnanHxejibHOM npouecce B 3y6o-iejnocxHOH cncxeMe). Ha (jxane
HMMyHO7ie4)HIIHXHblX COCXOaHHH HHHUJIHpyiOX OCTpblH pHHOCHHyCHT, Ipn6KH, XJiaMH-
flHH, pa3HOo6pa3Hbie conexaHHa MHKpo<J)Jiopbi. TaKxinca jieHCHHa BHe6ojn.HHHHbix H
rocnnxajibHbrx 4>opM ocxporo pHHOCHHycHxa snanHxejibHo oxjiHHaexca.
127
KnuHUKa. OcxpbiH rafiMOpHX BHpycHofl sxHOJiorHH name Bcero npoxBKaex
6eccHMnxoMHO na (})OHe OPBH, CKJIOHCH K caMOpaspemeHHio. BaKxepnajibKbiH
ocxpbiH raiiMOpHX pasBHBaexca K 7-14-My jaao ocxporo nacMopxa H HMCCX xapaKTepHyio KJiHHHKy. BojibHbie acajryioxca na roJiOBHyto 6oJib, ycHJiHBaiomyioca
K aenepy, 6ojib, xaxcecxb B npoeKUHH nasyxH, oco6eHHO Bbipa»ceHHyio npn naKJIOHC roJiOBbi Bnepefl. BbipaxcenHOCXb saxpyflHCHHa HOCOBOPO flbixaHHa saBHcnx
OX aHaXOMHHCCKHX OCo6eHHOCXCH nOJIOCXH HOCa H KOJIHieCXBa OXflCJiaCMOrO H3
BepxHenejuocxHOH nasyxH. FIpH o^HocxopoHHCM rafiMopHxe HacMOpK xaKace
npHo6pexaex oaHocxopOHHHH xapaKxep H cooxsexcTByex cxopone nopaxcenHa.
PHHOCKonHHecKaa KapxHHa sasncHX ox cocxoaHHa ecxecxBenHoro coycxba nasyXH H KOHCHCXCHUHH 66 COflepHCHMOTO. HepCflKO H3 (JjOHC OX6HHOH, THnepeMHpOBaHHOH CJIH3HCXOH HOC3 B CpCflHCM HOCOBOM XOfl6 BHflHCeXCa HOJIOCKa FHOH
(CHMHXOM OpeHKejw). IIpH coiexaHHOM BocnajieHHH raiiMopoBOH H peiuexnaxoH
nasyxH xapaicrepeH CHH^POM «nocx-Ha3ajii.HOH pHHOppeH», Kor^a ox^ejiaeMoe
cxeKaex B nocoraoxKy, Bbisbmaa xapaKxepHbie rjioxaxejibHbie flBH»ceHHa, noKainJIHB3HH6, cnoco6cxByex pacnpocxpaHCHHio BocnsjieHHa Ha ycxta cjiyxosbix xpy6.
flpx flHarHocxHKH Hcnojibayiox peHxreHorpa<J)Hio npnaaxonHbix H33yx HOCS.
PCHXTCHOJIOrHHeCKHMH npH3HaK3MH OCXpOrO pHHOCHHyHXa aBJiaiOXCfl CHHHCCHH6
nH6BMaxH33HHH nasyxH H HajiHine ropHSOHxaubnoro yposna »CHJKOCXH B npoeKU.HH nasyxH. Bee 6ojibiuyio pojib npnoGpexaex KOMHbioxepHsa xoMorpa<J)Ha npnasxoHHbix nasyx Hoca.
OcxpbiH sxMOHflHX HaH6ojice Hacxo BCXpeHaexca B aexcKOH npaKXHKe, Moacex
pasBHXbca y pe6eHKa panHero sospacxa. Y sspocjibix ocxpbiH STMOH^HX, KaK npaBHJIO, coiexaexca c BocnajieHHCM raHMOpoBOH H/HJIH Jio6HOH nasyx. BeayuiHMH
»caJio6aMH y 6o;ibHbix ocxpbiM sxMomnrroM aBJiaroxca saxpyflHCHHe HOCOBOFO awx3HHa, cHHaceHHe o6oHaHH« H BMecxe c XCM ourymeHHe HenpHaxHoro sanaxa y ce6a B Hocy. PnHoppea npHoSpexaex «nocxHa3ajibHbiH» xapaKxep. IIoaBJiaexca omymeHHe xaxcecxH, pacnnpanHH B oGjiacxH Kopna noca. V aexeft Hepe^KO Bcxpenaexca
nacxo3Hocxb KOXCH B oGjiacxn Kopna noca — «pacuiHpeHHe nepeHOCHinj». '
OcxpbiH <J>pOHXHx xapaKxepnsyexca BbipaxceHHOH FOJIOBHOH 6ojibK> B o6jiacxn
Ji6a, nocxoaHHOH B xeneHne mx, cna6o KynnpyeMOH npneMOM aHajibrexHKOB. 3aHOCOBOro awxaHHa H xapaicrep HacMopKa sasncax ox cocxoaHna BHKanana nasyxH H BOBJieneHHOCxH flpyrax OKOJIOHOCOBHX nasyx B socnanpouecc. HocKOJibKy y oanoro 6ojibHoro name Bcxpenaexca KOM6nCHHycnxoB, TonnnecKaa flHarnocxHRa xojibKO no KJiHHHKe nepeflKO saa, B csasn c HCM neo6xoflHMO npoBcaeHHe peHxreHOJiorHHecKoro nccjienpHflaxoHHbix nasyx noca.
ocxporo c^eHOH^Hxa xapaKxepnbi rojioBHbie 6o;iH B o6jiacxn saxbijiKa,
raasa. CjiHsncxo-rHOHHoe oxaejweMoe cxeKaex no saflHen CXCHKC FJIOXKH. BojibHOH omymaex HenpnaxHbiH rHHjiocxHbiH sanax B nocy. HaH6ojibiHHe
CJIH3HCXOH O6OJIOHKH Ha6jIK)flaK)XCH B 33flHHX OXfleJI3X HOJIOCXH HOC3,
HO cKonjieHHe cjiH3Hcxo-rHOHHoro oxflejiaeMoro B Kynojie HOCOFJIOXKH.
128
Teiwa VII. SAEOJIEBAHMflHOCA M OKOJIOHOCOBblX HASYX
Jleienue. HaH6ojiee 3(})4)eKXHBHO JieneHHe ocxporo pHHOCHHycnxa B
KOMiuieKCHoro BosflCHCXBHa na ace npoaBJieHHa BOcnajinxejibHoro npoijecca H
o6ecneHeHHa flpennpoBaHHa nopaKCHHbix npH^aroHHbix nasyx noca.
CymecTByroT pasJiHiHbie cnoco6bi apeHHposaHHa napanaaajibHbix CHHycoa.
HanGoJiee npocxofi — aHCMHsanHfl cpeanero HOCOBOFO xoaa. K co>KajieHHio, sxox
cnoco6 HC Bcer^a 3<}>c[)eKXHBeH. IIInpoKO ncnojibsyexca npoMWBaHHe HOJIOCXH
Hoca MCXOAOM nepeMemcHHa »cHflKocxH (no Upoexny). Ilepefl JieneHHCM npofloflax aHCMHsauHio CJIHSHCXOH HOJIOCXH noca. IlpH npOBeijeHHH npouejrypbi 6ojibHOH JieHCHx HE CHHHC H 6es ocxanoBKH noBxopaex CJIOBO «icy-Ky», HXO H nocnyHCHJIO HasBaHHCM Mexofly. B 3x0 BpeMa B oflny nojioBHHy Hoca Harnexaexca anxHcenxHHecKHH pacxBOp (<J)ypaHHjiJiHHa, xjiopreKCHflHHa, MajiaBHxa H x. #.), a HS
apyroH y/jajiaexca npn noMomH sjiexpooxcoca. BapnanxoM sxoro Mexoaa JICHCHHS aajiaexca BOJXHo-cxpyHHoe npoMbiBaHne HOJIOCTH noca, ncnojibsyeMoe y fleXCH paHHero Bospacxa. B OCHOBC BOflHo-cxpyftHoro npOMbisaHHa JIC»CHX 33KOH
coo6maiomHxca cocy^oB. Tenjibifi 4>H3HOJiorHHecKHH pacxBop noMemaiox B mxaXHB Ha Bbicoxy OKOJIO 1,8 Mexpa, rojiosy pe6eHKa HaKJionaiox naa paKOBHHOH JIHUOM BHH3 xaK, Hxo6w MeyKffy (JjjiaKOHOM c pacxBopOM H rojioBOH pe6eHKa 6buia
no Bbicoxe OKOJIO 0,8-1 Mexpa. IlpOBOflHHKOM pacxsop coe^HHaiox c
nojiOBHHOH Hoca pe6eHKa, HJIOXHO o6xypnpya KaHronefi Hos^pro. ^CnflKocxb nocxynaex B nojiocxb noca no saKony cooGmaromnxca cocy^oB H CBo6oflHO BbixeKaex us flpyron nojioBHHbi noca. B nocneaHee spema jxna jieneHiw ocxporo rHOHHoro pHHOCHHynxa mnpoKO Hcnojibsyioxca ^[MHK-Kaxexepbi. IlpHHUHn
flMHK-Kaxexepa — cosflanne oxpniiaxejibHoro flaBJieHHa B O^HOH noHOCOBOH nojiocxH, Hxo cnoco6cxByex nocxynjieHHio rHOHHoro
Moro as OKOJioHocoBbix nasyx B nojiocxb Hoca. ]\fvi npnuejibHoro
OKOJIOHOCOBHX nasyx ncnojibsyiox nyHKUHH. IlyHKUHa BepxHenejiiocxHOH nasyxn
npOBOflnxca HFJIOH KyjiHKOBCKoro. Hoa MCCXHOH annjiHKaqHOHHOH anecxesHeH
nepes HHMCHHH HOCOBOH KOR, oxcxynHB OKOJIO 1,5 CM ox nepeflHero KOHua HH»CHCH HOCOBOH paKOBHHH, npoHSBOflax npoKOJi MeflHajibHOH CXCHKH nasyxH. Ilocjie
3BaKyauHH 3Kccyaaxa nojiocxb nasyxn npOMbisaexca pacxsopOM anxncenxHRa,
no noKasanHaM aHTH6noxHKH, 4>epMeHxw, cocyaocyacHBaiomHe H ropcpeAcxsa. IlpH Heo6xo«HMOCXH jxjuixeJibHoro nocxoaHHoro flpeHHB nasyxy ycxanaBJiHBaexca njiacxHKOBbiH Kaxexep, lepes Koxopbifl ocymecxBJiaexca npOMbiBaHne nasyxn. .UpeHHpoBaHne jio6HOH nasyxn nposo^Hxca c
noMombio nyHKnHH nasyxH nepes HHXCHIOIO cxeHKy no K). A. YcxbanoBy (CM.
PHC. 10 FIpHJioMceHHa) Jin6o xpenaHonyHKinieH nepes nepe^Hioio cxeHKy nasyxn.
nyHKUHH jioGnoH nasyxn no K). A. YcxbanoBy Hcnojibsyioxca npaMbie XBepHrjiu xHna HFJIU H. A. KaccnpCKoro, HMeiomHe orpaHHHHxejib (CM. pnc. 11
HpHJioKeHHa). TpenaHonyHKiuia jioGnoH nasyxH npoBOOTTca c noMombio MexaHHHCCKOH apejiH, 3JieKxpoxpenaHa, 3y6oBpane6Horo 6opa, xpoaKapa H x. a.
apeHHpoBaHHa jioGnoH nasyxH nocjie xpenaHonyHKUHH ncnojibsyexca
naa MexajuiHHecKaa Kanrojia. flfiA flpeHHpOBanpia pemexHaxOH nasyxn xaicace
IV. Bocna/iMTenbHbie 3a6oneBaHna OKonoHOCQBbix naayx
129
OHHCaH nyHKUHOHHblH MCXOfl, HO BBHJjy BO3MO»CHbIX OCJIOaCHCHHH OH HC HaiUCJI
UIHpOKOrO npHMCHCHHa B KJIHHHKC, HaiUC HCHOJIbSyiOX npOMbIB3HHe nOJIOCXH HO-
ca pasjiHHHHMH MexojjaMH, Koxopwe 6ojiee Sesonacnw H xexHHHCCKH npocxbi.
Hs MeflHKaMCHxosHbix cpejjcxB JXIIH jieieHHa CHHycHxos Hcnojibsyiox:
MecxHbie H CHCxeMHbie fleKOHrecxanxbi;
aHXHFHcxaMHHHbie npenapaxw;
MyKoaicxHBHbie npenapaxw;
xonHiecKHe aHXHMHKpo6Hbie cpeacxsa;
6aKxepHH;
AHTH6aKTepnajibHan Tepannn. Ocxpbie EHpycnwe pHHOCHnycnxbi, npoxena (})OHe OPBH, HC xpeGyiox HaaHaneHHa anxnGHOXHROB H Kyraipyioxca
BMecxe c npoaBJieniMMH ocxporo pHHuxa. IIpH JICFKHX ^opMax GaKxepnajibHoro
pHHOCHHycHxa Hasnanaiox xonHHecKHe aHXHSaicxepHajibHbie npenapaxw H anxncenxHKH (BnonapoKC, IlojiHfleKca, pacxsop KOJiJiaprojia, jxnoKCHflHHa H x. a.). /Ina
jieneHHa cpeaHexaHcejibix H xaacejiwx 6aKxepHanbHbix ocxpbix CHHycHTOB Hcnojibsyrox CHCxeMHbie amuGHOXHicH. IIocKOJibKy HH KJiHHHHecKaa Kapxnna, HH peHxreHOJiorHHecKoe HccjieaoBaHHe He aarox npejjcxaBJienHa o XOM, aBjiaexca pHHOCHHyCHX BnpycHbiM HJiH 6aKxepHajibHbiM, xo, Hasnanaa anxnGHOTHKH, cjiejryer pyKOBOacxBOBaxbca o6mnM cocxoaHHCM 6ojibHoro, Hcano6aMH, HajiHHHeM moHHoro oxaejiaeMoro B HocoBbix xoflax.
O6biHHO nofl6op aHxn6HOXHKa ocymecxBJiaexca sMnnpHHecKHM nyxeM. CornacHO npoBeacHHbiM HCcneaoBaHHaM MHKpo4>Jiopbi nojiocxH Hoca H ee HyBCXBHxejibHOCXH K aHXH6HOXHK3M, npenapaxaMH nepBoro Bbiobpa aBjiaioxca nojiycHHxexHHecKHe
neHHUHJUiHHbi, aKXHBHbie B oxHomeHHH p-jiaicxaMasHbix KOKKOB — aMOKcmoiaB (BMcoKaa HyBCXBHxejibHOCxb MHKpo<})Jiopbi Ha6jnoflaexca B 93 %), ne4)ajiocnopHHbi II H
HI noKOJieHHH: ne4>xH6yxeH, ne^aicnop, neacKc, KJia4)opaH (BbicoKaa HyBCXBHxejn,Hocxb MHKpO(|)Jiopbi — OKOJIO 87 %). IlpH HenepcHOCHMOcxH neHHUHJiriHHOB H ne4>ajiocnopHHOB aubxepnaxHSHbiMH npenapaxaMH flJia Bspocjibix aBjiaioxca «pecnnpaXOpHblO) 4>TOpXHHOJIOHbI (TaB3HHK, KcCHaKBHH - BblCOKaa MyBCXBHXejIbHOCXb MHK-
po4>Jiopbi — CBbiuie 95 %). y flexefi ao 16 Jiex, yrnxbrnaa HeSjiaronpHaxHoe BjmaHHe
CPXOPXHHOJIOHOB Ha pocx xpameBOH xKann, npenapaxaMH 2-ro paaa asjiaioxca M3Kpojnmbi — posaMHUHH, MaKponen (swcoKaa HyBCXBHxejn>Hocxb MHKpo4)Jiopbi —
OKOJIO 70 %). Kypc JienenHa cocxaBJiaex 5-7 flHefi. 34>(})eKXHBHOCTb aHXH6HOXHKa
npoaBJiaexca B nepBbie xpoe cyxoK: npn oxcyxcxBHH apKon nojioaorrejibHOH ,tnfflaMHKH sa 3xox nepnoa Heo6xoflHMO CMCHHXb aHXH6aKxepHanbHbiH npenapax.
IlaToreiieTHMecKan repaniiH Hcnojitayexca B flonojinenHe K aHxn6HOTHKaM,
a B cjiynae JICFKHX H HeocjioaoieHHbix <j)opM ocxporo pHHOCHHynxa MOHCCX asJiaxbca caMocxoaxejibHOH xepanneH. CospeMeHHWH 4>apManeBXHHecKHH pbmoK
npeflcxasjiaex orpOMHoe KOJIHHCCXBO MeflHKaMCHxoB, ncnojibsyeMbix ana JieieHHa pHHOCHHyCHXa.
130
Teiua VII. 3AEOJ1EBAHHflHOCA M OKOflOHOCOBblX RA3YX
cocyaocy»cHBaiomHe cpeacxsa HHXpanasajibHoro (na(})XH3HH, KCHMCJIHH, CaHOpHH H T. fl.) HJIH HepOpajIbHOFO (KOJM3KX, KOHX3K) H33H3HC-
HHa Bceiyia Heo6xoflHMW AIM JieneHHa pHHOCHHycnxa. 3xH npenaparbi B KpaxHaHuiHH cpOK ycxpanaiox OXCK CJIHSHCXOH, BOCCxanaBJiHBaiox HOCOBOC flbixanne H
npoxoTXHMOcxb ecxecxBCHHbix oxsepcxKH npHJiaxoiHbix nasyx noca. OflnaKO BCC
cocynocy>KHBaioiH,He npenapaxw HMCIOX no6oiHbie scjxjjeicxbi, K KoxopwM OXHOCaxca CHMHXOM pHKOUICXa H MeflHKaMCHXOSHblH pHHHX, B CBS3H C HCM COCyflOCy-
HCHB3K>mHe npenapaxw peKOMeHAyrox ncnojibsoBaxb He 6ojiee 5-7-H aneH.
Bojibiuoe 3HaieHHe HMCCX <f>opMa BbinycKa npenapaxa. KaiuiH HesosMOKHO 403HpOB3Xb, XaK K3K 6oJIbIIiaa H3CXb p3CXBOp3 Xyx 5KC CXCK3CX B FJIOXKy HO flHy HOJIOCXH HOC3. B 3XOM CJiyH3C HMCCXCa On3CHOCXb HCpeflOSHpOBKH Hp6H3p3X3 6e3
)KejiaeMoro atJxfeKxa. HaMHoro 6ojiee Bbiro^HbiM B SXOM caexe BbiHasHaieHHe ^osHpoBaKHbix cnpees. IlepopajibHbie ^eKonrecxaHXH HC BHswBaiox Me^HKaMeHxosHOro pHHHxa. Ho npn HX npneMC 6bmaex 6eccoHHHija,
noBbiuieHHe apxepnaiibHoro flaBJienna, xaxHKspflna. 3xn npenapaxw cinxaioxca
flonHHroM y cnopxcMCHOB, HeacejiaxeneH HX npneM aexbMH no 12-H nex.
AHXHFHCXSMHHHbie npCH3p3XbI HCHOJIbSyiOX B JICHCHHH pHHOCHHyCHX3 UIHpOKO, HO H3 33JIO>KeHHOCXb HOC3 OHH BJIHHIOX M3JIO. Hx UCJieCO06p33HO H33H3-
qaxb na <j>OHe aruieprHqecKoro pHHHxa HJIH na paHHen «BHpycHOH» cxa^nn PHHOCHHycHxa, Koraa HMeexca BwpsaceHHaa pHHOppea. Cjie/ryex noMHHXb, HXO anxnmcxsMHHHbie npenspaxbi 2-ro noKOJieHna HCJibsa conexaxb c MSKPOJIHJJSMH H
npoxHEorpnGKOBbiMH cpe^cxBaMH, xaK KaK OHH ycHJiHsaiox KspaHOTOKCHHCCKHe
CBOHCXB3 3XHX npoxHBOMHKpoSHbix npcnapaxoB.
MyKoaKTHBHbie npenapaxbi name HasHanaioxca ana jieneHna saxaxcnoro xeHBHHa OCXpOrO pHHOCHHyCHXa HJIH npH o6oCXpCHHH XpOHHieCKHX CHHyCHXOB. B
33BHCHMOCXH OX HCJIH, C KOXOpOH H33H3HaCTCa HpCHSpaX, MOXCHO:
BOSflCHCXBOBaXb H3 Ba3KOCXb CJIH3H (AE[Ll, CHHynpCX, pHHO(j)JiyHMyUHJl);
— ycKOpnxb xpsHcnopx CJIHSH (MCXHJIKCSHXHHH, aM6pOKCOJi);
BHyxpHKJiexoHHoe o6pa3OB3HHe CJIHSH (apecnan, xonniecKHe
l, aHXH6HOXHKH-M3KpOJIHJZU).
Jlnsaxbi 6aKxepHH — BaioiHHbi TJJW HHip3H333JibHoro HJIH nepopajibHoro
npHMCHCHHa (6pOHxoMynaji, pn6oMyHHJi, HPC-19, HMMyaoH) cnoco6cxByiox
6bicxpOH BbipaSoxKe MecxHoro HMMyHHxexs. BSKUHHH Hcnojibsyioxca KSK B
K3iecxBe npo4>HJiaKXHHecKoro cpeflcxaa, xaK H ana jieneHHa ocxporo pHHOCHHycnxa. Onxonpenapaxbi H roMeonaxHHecKHe cpe^cxaa, o6jiaflaiomHe npoxHBOBOcnaJIHXejIbHHM H MyKOJIHXHHeCKHM flCHCXBHCM (CHHynpCX, XOHSHJIbFOH, 3n3M H X. fl.)-
XpOHHHecKHe CHHycHTbi. npeapacnojiaraiomHMH 4>aKxopaMH pasBHrna xpoHHHecKoro CHHycHia aBJiaioxca nscxbie OP3, HapyuieHne a3pauHH npHflaxoHHbix na3yx Hoca, KaK npaBHjio, na 4>OHe cxoracoro napyuieHHa HOCOBOFO JibixaHHa. Ilpn xpoHHHCCKHX KaxapajibHbix H rHOHHbix <J>opMax CHHycHxa »cajio6bi noaBjiaroxca B nepn04 oGocxpeHHa 3a6ojieBaHHa H npaKXHHecKH ne oxjinnaioxca ox acanoS npn ocxpOM
BocnanHxejibHOM npouecce. PHHocKonHnecKaa KapxHHa B nepnoa oGocxpeHHa xaicace
IV. BocnanmenbHbie aaSoneeaHMfi oKonoHocoBbix naayx
131
HflCHXHHHa. OflH3KO B CXaHHK) pCMHCCHH BOCHaJIHXeJIbHbie HSMCHCHHa CJIH3HCXOH
OKOJiOHOCOBbix iiasyx coxpanaioxcH, HXO MOXCCX o6ycjiOBJiHBaxb «6ecnpHHHHHbie»
rojiOBHbie 6ojm no Beiepaivi, a xaicace nocjie 3MOUHOHajn>HOH, (^HSHHCCKOH narpysKH;
HeaoMoraHHe; cy6(J)e6pHJibHyio Jinxopajicy. CoxpaHaerca acajioSa na nocxoaHHoe
HJIH Hacxoe saxpynHeHHe HOCOBOFO flbrxaHHa. Ilpn pHHOCKonHH B cxaarao PCMHCCHH
CHHycHxa MOHCHO yBHaexb sacxoHHO-rHnepeMHpOBaHHyio CJiH3Hcxyio, oxaejiaeMyio B
BHfle HOJIOCKH moa B cpeflHCM HOCOBOM xo^e HJIH ynacxKH rycxbix CJIHSHCXOrHOHHbK H3JIO»CeHHH H3 HOCOBbDC paKOBHH3X.
Jlenenue xpoHHHCCKoro KaxapajibHoro H moHHoro CHHycnxa B cxa^HH 060cxpeHHa KOHcepBaxHBHoe c npHMCHCHHeM aHXH6noxHKOB, anxHcenxHKOB, JJCKOHrecxanxoB, aHxnrHCxaMHHHbix npenapaxos, jinsaxoB 6aKxepHH H apymx cpe/jcxB,
npHMenacMbix fljia jieneHHa ocxporo CHHycHxa. B cxaijHio PCMHCCHH JieieGHbie
MeponpnaxHa nanpaBJieHbi Ha ycxpaneHHe npnHHHHoro 4>aicxopa CHHycnxa. 3ro
MO^cex Sbixb H onepaxHBHoe BMeuiaxejibcxBO fljia KOppeKunn HOCOBOFO flbixanna
HJIH HMMynoKOppeKUHa, saKajiHBaHHe, npoxHBoajiJieprHHecKoe jienenHe H x. %. B
cjiy«iaax, Kor^a pasBHBaioxca rHOHHbie BHyxpHrjiasHHiHbie, BHyxpHiepenHbie ocjioHCHCHHa, xpoHHHecKHe $opMbi KaxapajibHoro H rHOHHoro CHHycHxa noaneacax
onepaxHBHOMy JieneHHio. OnepaxHBHoe jieienHe xakace noKasano npn rHnepmiaCXHHCCKHX 4>opMax xpOHHHecKoro CHHycHxa.
PaduKOJibuan onepatfux na eepxHeHejitocmnou nasyxe (onepaifnx KajideejuiaJIwKa). ITpoBo^Hxca non o6mefl HJIH no^ MCCXHOH anecxesHeH. B npeAHsepHH
HOJIOCXH pxa co cxopoHbi nopa»ceHHOH nasyxn nponsBOixax paspea CJIHSHCXOH H
naTjKOcxHHUbi no nepexoflHofi CKJia^Ke BepxHefi HCJIIOCTH ox Bxoporo ao nexBepxoro-naxoro 3y6a. PacnaxopoM oxcjiaHBarox H cflBHrarox HaflKOCXHHiry Ksepxy,
o6na»caa coGaibio aMKy. YnacxoK nepeAHen CXCHKH BepxHenejiiocxHOH nasyxn
pesennpyiox, y^ajiaiox HS nasyxn naxonorHHCCKoe co^epacHMoe, B o6jiacxn HHKnero HOCOBoro xo/ja HaioiaabiBaiox coycxbe c nojiocxbio noca. Ha cjinsHcxyio
o6ojioHKy npeflUBepna poxoBoft HOJIOCXH HaKjia^HBaiox IIIBH. OxHomeHHC K CJIHSHCXOH oGojioHKC nasyxH MaKCHMajibno majjamee, HeHSMCHeHHyio cjiH3Hcxyio
Bceraa coxpanaiox. Ilocjie onepauHH nasyxy pbixjio xaMnoHHpyrox MapjieBbiM
xaMnoHOM c aHXH6noxHKOM HJIH anxncenxHROM, yjjaJieHHe xaMnona npOBO^ax na
cneayromHH aenb HJIH Ha sxopbie cyxKH (B cjiynaax HHXpaonepauHOHHoro KposoxeneHHa). B nocjieonepaunoHHOM nepnoae nasyxy Heo^HOKpaxHO npoMbisarox
nepes c<J)opMHpoBaHHoe coycxbe.
3HdoH03cuibHoe ecKpbimue eepxHenejuocniHOU nasyxu npOBOAax y aexen flo
7 Jiex, a xaK»ce y Bapocjiwx noa o6mHM HJIH MCCXKHM o6e36ojiHBaHHCM. IlpeHMyuiecxBCHHO BCKpbixne nasyxH ocymecxBJiawx nepes HH»CHHH HOCOBOH XOA.
HHMCHIOK) Hocosyio paKOBHHy HaflJiaMbiBaiox H oxraGsiox KBepxy, 3 npn ee BWpsaceHHOH rHnepxpo(J)HH HSCXKHHO peseunpyiox. BcKpHBarox nasyxy B XOM »ce
Mecxe, rfle H npoBOflax nyHKUHio — y Mecxa npHKperuieHHa, npaKXHiecKH nofl
cepeaHHOH HOCOBOH paKOBHHbi. Jlflx BCKpwxHa HcnoJib3yiox ocxpyio jioacKy,
xpoaKap, xpoaKap-BbiKycbiBarejib. nocjie pacuinpeHHa oxBepcxna B KOCXH ocxpofl
132
Teivia VII. 3AEOJlEBAHMflHOCA M OKOJIOHOCOBblX F1A3YX
HJIH aoJioxoM (sccrfla Knepean) BbipaBHHsaiox nopor B o6nacxn MCJJHCXCHKH nasyxH H <J>opMHpyiox mnpOKoe coycxbe, nepes Koxopoe yaajwiox
naxojiorHHCCKoe coaepxcHMoe nasyxn. IlocJie onepauHH B coycxbe na O^HH cyxKH
BBOJiHXC» MapjieBbiH xaMnoH c aHXHcenxHKOM.
BcKptixne KJiexoK peuiexnaxoro naSnpHHxa K3K npasHJio npoHSBOjxax nepea
coBMecxHbie CXCHKH npH BCKpwxHH raHMOpOBOH HJIH jio6HOH nasyx. 3naoHasajibHWM nyxeM MOXCHO BCKpuxb aneHKH pemexHaxoH nasyxn, oxorayB KBepxy
HJIH qacxHHHO peseuHpya cpeaHioio HocoByro paKOBHHy.
PaduKajibHaa onepaifux no6nou nasyxu (no Kwuiuany). Opn sxoft onepauHH
BCKpuxHe xojibKO Jio6HOH nasyxH coiexajox co BCKPWXHCM nepeaHHx, cpeannx, a
B cjrynae HeoGxoaHMocxH H saannx KJICXOK peuiexqaxoH KOCXH H KJIHHOBHJIHOH
naayxH. Paapea KO>KH nposoflsiT no 6poBH, npofloji^caa ero flyroo6pasHO KHHsy ox
MeflHajibHoro Kpaa 6posH flo yposna HH»Hero KOHua HOCOBOH KOCXH. 3axeM pacceKarox H pasflBHraiox najj;KocxHHiiy. BcKpbixne nasyxn ocymecxBJiaiox nepes ee
nepeflHioio cxeHKy. CjiHsncxyio o6ojiOHKy naayxn xmaxejibno BbicKa6jiHBaiox,
yflanxiox naxojiorHHecKHe XKaHH ycxba HOCOJioGnoro Kanajia, <})opMHpyiox mnpoKOC coo6meHHe Mexyjy jio6HOH nasyxofl H nojiocxwo noca.
V. PMHOfEHMblE OPBHTA^bHblE OCJlOKHEHMfl
AHaxoMO-xonorpa4>HHecKHe BsaHMOoxHomeHHa npHflaxo^Hbix naayx noca H,
a xaicwe MHoroHHCJieHHbie anacxoMosw HX cocyjjHcxbix cexeii cosaaiox
m pasBHXHH BHyxpHop6HxanbHbix OCJIOHCHCHHH. KpoMe aHaxoMHHCCKHX ycjioBHH, 6ojibiiiyio pojib B BOSHHKHOBCHHH BHyxpHop6HxajibHbix OCJIOHCHCHHH Hrparox ajuieprHsauHa H HMMyHHOfleiJmiiHXHbie cocxoflHHa. Hacxoxa BnyxpHFJiaSHHHHblX OCJKMKHCHHH y flCXCH BblUIC, H6M y BSpOCJIblX, HCMy CnOCo6cXByiOX
BospacxHbie ocoSeHHOcxH KOCXHHX CXCHOK OKOJIOHOCOBblx nasyx. y aexefi, 6ojibHbix CHHycifraMH, BHyxpHOpGHxajibHbie ocjiojKHCHHa pasBHBaioxcx B 0,5-14,7%
cjxynaeB, y sspocjibix — ox 0,5 flo 8,5 %. CxaxHcxHnecKHe aamibix paanbix KJIHHHK
Moryx SHaiHxejibHO oxjinnaxbca, nocKOJIbKy 3XH 6ojibHbie npoxoaax jieneHHe KaK B
JIOP-, xaK H B o(J)xajibMOJiorHHecKHX H HHiJieKUHOHHbix cxauHonapax.
CoraacHO KJiaccHiJjHKauHH pHHorennbix opGHxajibHbix ocjio>KHeHHH no
B. B. UlespbirHHy (1976), paajinnarox HerHOHHbie H raoKHbie nopaacenHH op6nxbi.
K HerHOHHbiM npoueccaiw oxnocaxc«:
— OXBK BCK rjiaaa;
— OXCK opGnxajibHOH KJiexnaxKH;
— nepnocxHx opGnxw.
FHOHHbie npoueccbi:
— a6cueccbi BCK;
— cySnepHOCxajibHHH a6cuecc;
CBHIUH BCK H FJiaSHKHHOH CXCHKH;
V.
op6nranbHbie
133
— pexpo6yjib6apHWH aScuecc;
— cenxHHecKHH xpoM6o3 BCH op6nxbi;
— 4)JierMOHa opSnxbi.
K CHMinoMaM nopaaceHHa op6HXbi oxnocaxca: ronoBHaa 6onb, GOJIH B o6jiacxn
raasa, OXCK HJIH HH(J)HJibXpauHa BCK rjiaaa, 3K3O(J)xajibM, xeMO3, CMemeHHC rna3HOro a6jiOKa, orpaHwieHHe ero nojjBHmiocxH, noBbiiueHHe xeMnepaxypbi xejia, BOCnajiHxejibHbie HSMeneHna co cxoponw KPOBH. Ilpn noflospeHHH na op6nxajibHoe
OCJIOHCHCHHe 6ojIbHOHflOJIMCCH6bIXb CpOHHO rOCHHXaJIHSHpOBaH B JIOP-OXflejICHHe.
BicnioHaex B ce6a ycxanoBJieHHe HCxoHHHKa HH<J)eKitHH opGnxw,
xapaKxepa npoqecca B OKOJIOHOCOBHX naayxax H pacnoanaBaHHe
BHfla op6irrajibHoro ocjioacneHHa.
PacnosHaBanne Bnaa op6HxajibHoro ocjioacHCHHa:
— OXCK BCK rjiasa — BCKH yiojimenbi, nacxosHW, rjiaanaa mejib cyxcena, FHnepeMHa KOHtroKXHBbi, HHorjxa XCMOS;
— OXCK op6nxajibHOH KJiexnaxKH — 3K3O(J)xajibM, no^BHJKHOcxb rjiasHoro
a6jioKa coxpaHena HJIH necKonbKo orpaHHqeHa, XCMOS;
— a6cuecc BCKa — XKann HH^HJibxpnpoBaHbi, 6ojie3H6HHbi, rnnepeMHa KOMCH, na omynb onpeaejiaexca (JunoKxyaqna;
— nepHocxHx — cMemeHHe rjiasHoro a6jioKa, njioxHbifi GojiesHenHbrii HH4)HJn>xpax B o6nacxH HH^cHeii, BHyxpeHHefi HJIH BepxHeBHyrpeHHeH CXCHKH opGnxbi;
— cy6nepHOCxajibHHH a6cqecc — CMemeHHe rjiasnoro a6jiOKa, (JwiioKxyHpyiomHii HH(j)HJibxpax B o6jiacxn HHXCHCH, BHyrpenHeH HJIH BepxHCBHyxpeHHeH
CXBHKH op6nxbi;
— pexpo6yjib6apHbiH a6cuecc — oxeK BCK, 3K3O(J)xajibM, XCMOS, orpaHHieHHC nojjBHHCHOcxH rjiasHOro »6jioKa BO BCCX HanpaBJieHHflx, 6ojie3HCHHOCXb npn
aasjieHHH na rjiasnoe a6jioKO, CHHweHne speHHa;
XpOM6o3 BCH OpGHXbl
OXCK BCK, 3K3o4>TaJIbM, XCM03, yCHJICHHC pHCyHKa
BBH KOJKH BCK, KOpHa Hoca, Ji6a, cenxHiccKaa xeMnepaxypa, o3Ho6bi, noxjiHBOcxb,
noflBH»cHocxb rjiasHoro a6noKa coxpaHena, aaBJieHne aa Hero GesGoJiesHCHHO,
3peHH6 MOJKCX 6bIXb CHHMCCHO;
— 4>jierMOHa op6nxbi — OXCK H HH<})HJibxpai;Ha BCK, XCMOS, 3K3o<J)xajibM, HCnojiBH^CHOcxb raasHoro a6jiOKa, pacinnpeHHe spaiKa, CHH»ceHHe speniw ao nonHOH noxepn, pesKaa 6ojie3HCHHocxb npn naJibnaqHH BCK H aaBJieHHH na rnasnoe
a6jiOKO, BbicoKaa xeMnepaxypa, HHor^a 6paflHKapjHa H psoxa.
Ocrpbrii CHHycHX, ocnoaaieHHbiH HerHoifflbiMH nopaaceHHaMH opGnxbi, noflne)KHX
KOHcepsaxKBHOMy JieneHHio. Hcnojn>3yexca Hacxaa aHeMHsausia nocoBbix XOJIOB, aHXH6aKTepHajn>Haa, npoxHBOBocnajnrrejibHaa xepairaa, nasHaieHHe acaponoHHacaioiuHX,
o6e36ojraBaioiimx H aHXHracxaMHHHbix npenapaxoB. IloKasaHbi nyHKuna H flpennpoBaHHe raHMOpoBOH nasyxH, xpenaHonyHKuna H apeHnpoBaHHC jio6HOH nasyxn. B xaacejibix cjiynaax npOBOJinxca HH<})y3HOHHHaa aesHHxoKCHKanHOHHaa xepanna.
OcXpblH HJIH XpOHHieCKHH CHHyCHX, OCJIOXCHCHHblH THOHHblM npOUCCCOM B
op6Hxe, xpeGyex cpo^Horo BCKpuxna nopaMcennbix OKOJionocoBbix naayx, ape-
134
Teiwa VII. SAEOJIEBAHl/lflHOCA H OKOJIOHOCOBblX HA3YX
HHpOB3HHa a6cueccoB, (JwierMOHbi HapyacHHM ^ocxynoM. XnpyprHnecKoe BMCmaxejibCTBO nporoBOflHxca COBMCCTHO c OKyjincxoM.
y flCTCH C Op6HX3JIbHbIMH OCJ10HCHCHHHMH, BbI3B3HHbIMH nOp35KeHHCM KJI6-
TOK pemexHaxoH KOCTH, B cjrynaax o6pa3OB3HHa cy6MyKO3noro a6ci;ecca peKOMemryexca ero anjioHasajibHoe uiHpoKoe Bctcpbrrae, saxeM no^cjiHSHcxo ocxpon
KOCXHOH JIOMCKOH BCKpbiB3ioxca nop3HceHHbie KJiexKH peinexnaxoro Jia6HpHHxa.
BHyrpunepenHbie puHOCMHycoreHHbie ocnowHeHMfl
3a nocjie^HHe 40 Jiex Ha 4>oHe o6mero coKpaiueHHa pasBHxna BHyxpHnepenHHX ocjiroKHCHHH, cxaxHCXHKa pHHoreHHbix BHyxpHiepenHbix OCJIOXCHCHHH oxjiHnaexca nocxoancxBOM. Xoxa BHyxpHHepenHbie pHHoreHHbie OCJIOHCHCHHH cocx3BJiaiox HC 6ojiee 10 % scex BnyxpHqepenHbix OCJIOHCHCHHH B oxopHHOJiapHHrojiorHH, CMepxHOCxb npH HHX oHCHb Bbicona H flocxnraex 30 %. BHyxpHiepenHbie ocjioacHCHHa name BosHHKarox npn 3a6ojieB3HHflx Jio6noH, iciiHHOBH4HOH,
peuiexnaxbix naayx, nocKOJibKy 3XH nasyxn HMCIOX c iqjenHHMH HMicaMH oGmHe
KOCXHHC CXCHKH. Peace HHiJieKUHH B nojiocxb icpena npOHHKaex reMaxoreHHbiM
HJIH JiHM^oreHHbiM iryxeM, xor^a HCXOHHHKOM HH^CKUHH Moryx 6wxb: 4>ypyHKyji
Hoca, a6cuecc HOCOBOH neperopo^KH, ocxpwH HJIH xpOHHnecKHH raiiMOpHx. Ilpn
nofloapeHHH na pHHoreHHoe BHyxpHqepenHoe ocjiowHCHHe noKasana cpo^Haa
rocnHxajinsauHa 6onbHoro.
fluazHocmuKa pHHoreHHbix BHyxpHnepenHbix bcjioacHCHHH BKnronaex B ce6a
ycxaHOBJieHHe HcxoHHHKa HH(J)eKUHH, onpeacjicHHe xapaKxepa npoqeccs B OKOJIOHOCOBHX naayxax H pacno3HaB3HHe BHfla BHyxpHHepennoro ocjioacneHHa.
KnuHUKa. PHHoreHHMH MeHHHFHx npoxeKaex xaxejiee, ^CM oxoreHHbra, iame
Ha6jiK)flaexca rjiy6oKoe yiHexeHHe uenxpsjibHOH HCPBHOH CHCXCMBI (KOMa, co). KjIHHHKO-aSrHOCXHHCCKHe KpHXCpHH CXOXCH C OXOrCHHblM MeHHHFHXOM.
KjiHHHK3 a6cueccoB nepeflHefi nepennoH SMKH o6biHHO ne
o6meMO3roBoii H onaroBOH CHMnxoMaxHKofi H o6Hapy5KHBaexca
HO na onepaiiHH, npeanpHHaxofi B CBHSH c OCJIOHCHCHHUM xeneHHCM ocxporo HJIH
o6oCXpeHHa XpOHHHCCKOrO 4>pOHXHXa (op6HX3JIbHOe OCJIOKHCHHe, OCXeOMHCJIHX
jio6HOH KOCXH). PHHoreHHbiH a6cuecc Mosra name jiOKajiroyexca B jio6HOH aone
Mosra H HMCCX xanyio ~x& oGmeMosrosyio CHMnxoMaxHKy, KaK H oxorenHWH. HeoSxoflHMO o6pamaxt BHHMSHHC H3 cjieflyiomHe onsroBbie CHMHXOMW nop3»ceHHa
jio6HOH aojiH Mosra npH xaacejioM XCHCHHH rHofebix cHHyHxca:
1. HsMeHCHHfl HCHXHKH, BblpaHCajOIUHCCfl B OXCyXCXBHH KpHXHieCKOFO OXHO-
meHHs K cBoeMy cocxoaHHro, 3H<})opHH, CKJIOHHOCXH K rpyGbiM, roiocKHM inyxKSM, XHiiHHHa Hep»uuiHBOCxB, HeonpaxHOCxb 6ojibHoro, peace Ha6jiioflaexcfl BHJlOCXb, SaMCflJICHHe flBHXCCHHH, HHCpXHOCXb, CnOHXaHHOCXb, 6e3bIHHUH3XHBHOCXb.
2. PacxopMTOKeHHe flpeBHHx noflKOpKOBbix pe(J)JieKCOB: Ha6jnoflaexca: «3BxoMaxHnecKoe XBaxaHne» — HenponsBOJibHoe cxBaxbmaHHe npe^Mexa npH KacsHHH HM JiaaoHH 6ojn>Horo; BbixarHBaHHe ry6 B BH^C xo6oxKa npn KacaHHH unraxeneM ry6, 00360-
V.
op6nTanbHbie
135
3; «$eHOMeH conpoxHBJieHHa» — npn nonbrnce BbisecxH xy HJIH HHyio nacxb xena
6ojn>Horo H3 cymecTByromero nojioxceHHa aBxoMannecKH HanpararorcH aHxaroHHcxwiecKHe Mbnimti, B cmiy qero Hccneflyioiipra HcnbrrbiBaex onpefleneHHoe conpoXHBjieHHe. HanpHMCp, npn nonbrrae npHnoflHaxb BcpxHee BCKO 6ojn>Horo (npe^ynpeflHB ero, Hxo6w OH axoMy He npoxHBHJica) omymsexca onpeaejieHHoe HenpoH3BOJn.Hoe
conpoxHBJieHHe (CHMHXOM H. K). KOXSHOBCKOFO); npHKOCHOBCHHe K ry63M
3bmaex cyzjopo»ffloe cacaxHe HejnocxeH (CHMIIXOM .HHmiieBCKoro). Mo*ex
ca Jio6Haa axaKCHa: npn croaHHH B nose PoMGepra H npn xo,zib6e GOUBHOH o6biHHO oxKJioHaexca B cxopony, npoxHBonojioxoryio onary nopaaceHHa B jio6HOH flOJie Mosra.
PHHoreHHbiH cencHC H xpoM6o3 KaaepHOSHoro cnnyca (aBjiaiomnnca H3H6oJiee HscxbiM BspnanxoM pHHoreHHoro cencHca) — HanGojiee xa»ejioe ocjio»HeHHC raoHHbix npoueccoB B o6ji3cxH nHua H OKOJiOHOCOBbix naayx. CBoeBpeMCHHaa AH3THocxHKa pHHoreHHoro cencHca nepeflKO saxpyAHena ns-sa MacKHpyioCHCXBHa
3HXH6HOXHKOB.
IlpHHHHOH XpOM6o33 K3BCpHO3HOrO CHHyC3
aBJiaexca ocjioxcHeHHWH (JtypyHKyji noca HJIH BepxHen ry6w, peace —
OCXpblH HJIH XpOHHieCKHH CHHyHX (3XMOHflHX, C^eHOHflHX, TSHMOpHX). KpOMC
,xoro, 3x0 ocjioacneHHe Moacex Ha6jnoAaxbca npn naxojiorHH sySonejiiocxHOH CHCTCMbi, rHOHHbix npoueccax B opGnxe, napa<J)apHHreajibHOM npocxpSHCXBe.
TnnHHHbie nyxn npOHHKHOBCHHa HH^CKUHH B nojiocxb nepens:
3) H3 JIHUeBOH BCHbl HCp63 yTJIOByK) BCHy B BCHH Op6HXbI, 3 33X6M B K3BCpH03-
HbiH CHHyc;
6) iepe3 peuiexnaxbie BCHH B BCHH op6Hxw, a 3axeM B K3BepHO3HbiH cnnyc;
B) ox BCH FJIOXKH, 3JibBeojiapHoro oxpocxKa — B KpbuioBHflHoe cnjiexeHHe,
saxeM B BCHW op6nxbi H K3BepHO3HbiH CHHyc;
r) KOHX3KXHHH nyxb pacnpocxpaneHHa HH(j)eKqHH B KasepHOSHbiH cnnyc npn
Y 60JIbHbIX FHOKHblMH npOUBCCSMH MarKHX XK3HCH JIHUa H OKOJIOHOCOBblX
nasyx cjie^yex o6pamaxb BHHManHe na cjie^yiomHe CHHapOMbi, XKHKHKBIC ww
K3BCpHO3HOrO CHHyCa:
1. CenXHHCCKHH CHHflpOM: O3HO6bI, npOJIHBHbie nOXbl, BblCOKaa HJIH pCMHXH-
xeMnepaxypa xejia, cyxon o6jioxceHHHH HSBIK, yBejiHHCHHe neneHH H ceJICSCHKH, Bbip3HceHHaa HHxoKCHKauna, HSMCHCHHa co cxopOHH KpoBH (rHnepJieHKOUHXO3, pC3KHH C/IBHF JieHKOU.HXapHOH (J)OpMyjIbI BJICBO, BblCOKaa CO3), H3MC-
MOHH (najiH^He 6ejiKa, raanHHOBbix HHJIHH^POB).
2. flncuHpRyjiaxopHbiH CHH^POM: OXCK KOHCH Ji6s H BCK oGonx ra33, pacuiHnOflKO»HbIX BCH, 3K304>X3JIbM, X6MO3.
3. O6meMO3roBOH CHHflpoM, o6ycjioBJieHHHH noBbimeHHeM BHyxpHiepenHoro fl3BjieHHa: roJiOBHsa 6onb, snsxna, paoxa BHC csasn c npneMOM nnmn, 6pa«HKap^na, aBJiCHHa sacxoa H3 rjiasnoM ^ne, noBbiuieHHe aaBJieHna cnHHHOMosroBOH XH^KOCXH npH JHOM6aJIbHOH HyHKUHH.
4. CnHflpoM pasflpaaceHHa Mosrosbix o6ojioneK: ixwioBHaa 6ojib, cBexoGob, o6m3a rnnepcxesHa, psoxa, pHrH^HOCXb MHUIU 3axbiJiK3, CHMnxoMbi Kep-
136
Tewa VII. SAEOJlEBAHMflHOCA M OKOJIOHOCOBblX HA3YX
HHra H Bpya3HHCKoro; npu JiK)M6ajibHOH nynKiiHH noBbiiueHHe
CIIHHHOMO3rOBOH JKHflKOCXH, HCpeflKO npHSHEKH BTOpHHHOFO FHOHHOrO MCHHHFHXa.
5. HespojiorHHecKHH CHiwpOM: npH3HEKH nopaHccHiw II, III, IV, V H VI HCpenHO-MosroBbix HepaoB (cHHJKeHHC speHHa, ^HiuioniM, aHHsoKopjw, nmecxesHa
K03KH Ji6a, HCBpanraa HaflrjiasHHHHoro Hepsa, cxoAameeca Kocorjiasne).
Ilpn MajicHiueM noflospeHHH HE pHHoreHHoe BHyrpHHepenHoe ocjioacneHHe
6ojibHbie noaneacaT cpoHHOH rocnHxajiHsaqHH B JIOP-oxaejieHHe MHoronpo4>njibHOH 6ojibHHUbi H xutaxejibHOMy o6cjieflOBaHHio c ynacTHCM oKyjiHcxa, HCBponaxonora, HCHpoxHpypra, peHxrenojiora.
HHoreHHbix BHyxpHHepennbix ocjioacneHHH
Hoca, ^peHHpoBaHHe nopaaceHHbix oKOJioaocoBbix nasyx napyjKHbiM ^ocxynoM);
— aaeKBaxHyro aHXH6aicxepHajibHyio xepanmo xopomo npoHHKaioiuHMH qepes reMaxo3Hue<i>ajiHHecKHH 6apbep npenapaxaMH (poue^HH, neHHUHJuiHH, neBOMHUCTHH). 3xn anxnGHOXHRH BBOflHTca BHyxpHBenqo, BHyxpHMbimeHHO, B XHHCCJIHX cjiynaax — BHyrpHapxepHajibno;
:— flernopoxaijHOHHyio xepamoo (npHMeHaiox jiasmcc, MaHHHxoji, MoiesHHy);
— CHMnxoMaxHqecKoe jieieHHe (aHajibrexHKH, cepfleHHbie, ceaaxHBHbie
cxsa).
XnpyprHHecKoe BMeuiaxejibcxso na jioSnoH nasyxe B CBHSH c
FHOHHblM MeHHHFHXOM (>6fl3aXeJIbHO SaBCpIliaeXCfl oGHaMCCHHCM XBepflOH M03FO-
BOH o6ojioHKH nepeflHCH nepenHoft HMKH. XHpyprHnecKoe JieneHne pHHorenHoro
aGcuecca Mosra ocymecxsjistexca COBMCCXHO PHHO- H HeftpoxiipyproM, CCJIH
THOHHHK pacnojiaraexcx He B jio6noH aone Mosra.
yxoiHCHiM jioicajiHsaiiHH aGcuecca npHMeH»K»xca aonojiKHxejibHwe MCcjie^oBaHHa (3JieKXpo3Hue(})ajiorpa4)iw, 3xo3Hqe<})ajiorpa(})HH,
xepnaa TOMorpa(J)HH, aHrHorpa(J)Ha H x. #.).
Bonpocbi MToroBoro KOHrponn 3H3HMM no xewe VII
1 . KaKne craflMM BbiAenaiox B paasuxnn cfcypyHKyna Hoca?
2. rioMewy 6onbHbie (pypyHKynow Hoca noflne>KaT oGnaaxenbHOM rocnuTannaaMMM B nOP-OTfleneHne?
3. HaaoBMxe ocHOBHbie npuMMHbi pasBuxna xpoHnnecKnx BocnannrenbHbix 3a6oneBaHMM nonocru Hoca n OKonoHOCOBbix naayx.
4. B MGM saKJiKHaeTcn rnaBHoe oxnMHue neMe6Hbix
npM OCTPOM PHHMT6 M CMHyCMTaX?
5. MTO 03HanaeT repiviMH «Ha(pTM3MHOBan 3aBMCMMOCTb
6. KaKMe aHxn6aKxepnanbHbie npenapaibi ncwasaHbi
6aKrepnanbHbix cunycHXOB?
7. KaKMe neKapcxBeHHbie npenapatbi Mcnojibsytoxcn
xpoHnnecKoro anneprvmecKoro pnHnxa?
8. B K3KMX cnynanx noKaaaHO xnpyprnMecrae neMenne
V. PnHoreHHbie opSnTanbHbie ocno)KHeHMa
137
XHpyprnsecKOM KOppeKqun HOCO9. MTO flBJiflercfl noKasaHneM
BOM neperopoflKM?
10. KaKMMn cnoco6aMM MO>KHO ocymecxBuxb flpeHnpoeaHne oKonoHOcoBbix nasyx?
1 1 . KaKne BbiAenniOT onaroBbie cuwnxoMbi a6cuecca jio6HOM flonn ronoBHoro Moara?
12. Ka«Me BbiAennioT CMHflpowbi npn pasBMTMH rpOM6o3a nemepMCxoro
CMHyca?
TOHSUJl/lOrEHHblE OCJ10)KHEHH«
139
B crpyKxype oxopHHOJiapHHrojiorHHCCKOH 3a6oneBaeMocxH B perHone 3aCH&HPH GOJICSHH TJIOTKH samiMaioT nepsoe MCCTO, 6ojibHbie 3a6ojieBaHHHMH FJIOTKH npCBajIHpyiOT H3 BCCX 3Tan3X OKaSaHIW IIJiaHOBOH H 3KCTpeHHOH
MeflHUHHCKOH noMoiijH. B OTopHHOJiapHHrojiorHiecKHx cxauHOHapax aaHHaa KEreropiM SojibHbix cocraBJiaex 40-45 %.
Ocrpbiii 4>apHHrHT — ocxpoe HH^eKijHOHHoe BOcnajieHHe CJIHSHCTOH 060JIOHKH raoTKH. 3a6ojieBaHHe BosHHKaex npH nona#aHHH B opraHHSM naroreHHbix
eiua VIM.
SAEOJIEBAHMfl PJIOTKM.
TOHSMJlJlOrEHHblE OCJlO)KHEHMfl
— 180
LJenb aaHflTMfl. Hsywrb xnnHMKy, fluamocTMKy H
npMHL|Mnbi jieMeHMn BocnannrejibMbix aaSonesaHMM ITIOTKM M TOH3MJ1/1OreHHblX OCTIO>KHeHK1M.
1. PaaoSparb KnuHMHecKne OTJIHMMH ocrporo cpan aHrMHbi.
2. HayHMXbCH flMtpcpepehmMpOBaTb cpapnHrocKonnMecKyio KaprnHy aHrnH.
3. OsHaKOMMTbCH c coBpeivieHHbiMM cpapMaqeBTMHeCKMMH npenaparaMU ana neneHMfi BocnanmenbHbix aaGoneBaHnii rnoTKn.
4. Paso6paxb KnunnKy, fluamocrnKy n npnm4nnbi
xpOHnnecKoro TOH3nn/iMTa.
5. OSHaKOMMTbCH C KHHHMHeCKHMH OCOSeHHOCTflMM
ripu nodzomoeKO K saHfimuio noemopumb:
OCOSeHHOCTM
J1MM-
rnoroHHoro KOJibqa
— Tonorpacpmo OKO/iornoroHHoro npocrpaHCTBa.
OcHaiueHHe. OcBeiMTenbHbie npn6opbi: MCTOMHHK
csera, no6HbiM pecfjneKTOp. fleMOHCTpaunoHHbiM warepnan.- nnaKaTbi, cnaPiflbi.
Ha6op MHcrpyweHTOB. HocoBbie aepKa/ia, oinaieJIM, HocomoTOHHbie aepKana, soHflbi HaenBHbie, nMHi46Tbi
HOCOBbie.
PaSoHee MCCTO. MHCTpyMeHTanbHbiM CTODMK, HacTonbHasi naivina, cnnproBKa, flsa cryna.
Macro npoBefleHMH sanmi^a. YHe6Hafl KOMHara.
PeKOMeHflyewaf) jiMTeparypa:
1. Condamoe M. E. JleKqun no OTOpuHOJiapMHronormi. — M.: MeflHUkina, 1990.
2. UleepbiauH B. B. PyKOBOflciBo no flercKOM oropn. — M.: MeanqMHa, 1985.
BHpyCOB HJM 6aKTCpHH, 3 TaKXCC npH aKTHBaqHH CHM6HOHTOB nOJIOCTH pT3 H
TJIOTKH nofl BOs^eHCTBHCM HeGjiaro-npHHTHbix <J>aKTOpOB — nepeoxjiaameHHa,
TpaBMbI PJIOTKH, BabIX3HH8 CflKHX XHMHHCCKHX BCmCCTB H T. fl. BojIbHWC >K3Jiy-
roTCfl Ha nepiiieHHe, cyxocxb, 5K»ceHHe, 6o;ib B ropjie. BbipaaceHHocTb AHCKOM4>opxa P33JIHHH3, HO oSmcc cocxoHHHe, KaK npasHJio, He cxpa^aex. B xo ace speMH, CCJIH HMCCX MCCXO OCTpblH pHHO(J)apHHrHX, XO BbIpa»CeHHOCXb o6mCHHXOKCHCHHflpOM3 pC3KO B03p3CX3CX. IIpH M63O({)apHHrOCKOnHH CJJH3HCX3«
THnepeMHpoBaHa, sepmicxa 33 cnex
ojuiKKynoB. He6Hbie MHHwaJiHHb
HX crji3»ceH, OT^ejweMoro B Ji3Kynax Hex. THnepeMHa H OXCK Moryx pacnpocipaaaxbca na H3flropx3HHHK H Hepn3JioH3flropx3HHbie cKJi3flKH. HepeflKO
p33BHBaCTCfl JIHM^aflCHHX nOflHCJIIOCTHblX JIHM(J)Oy3JIOB.
Jlenenue npOBOflHx xepanesx HJIH JIOP-Bpan B noJiHKJiHHHKe. Us flHexbi HCKnioH3K)x ocxptie, cojieHbie, ropaiHe npoayicrbi. DPOBOAHT nojiocK3HHe FHOXKH
p3CXBOp3MH 3HXHCeiIXHKOB (AKBHpHH, M3JI3BHX), OXB3p3MH JlCHeGHblX XpEB (lljajl-
<J>ea, poMaiiiKH, KaneHflyjibi). HasnanaiOT paccacbisaHHe xaftjiexHpOBaHHbix anxHcenxHKOB (CxpencHJic, Cenxojiere, OapHnrocenx, Ce6naHH H x. ^.). Ha <J>H3Honpoue^yp Hasnanaiox YOO CJIHSHCXOH FJIOXKH, BflbixaHHe nepes pox aaposojiefi BHOnapoKC, HPC-19, a xatoice xeroibie HHrajwqHH pacxsopa naHHOH coflw,
Tpas.
XpOHHHCCKHH (j)apHHfHT
XpOKHHCCKOC BOCnajlCHHC CJIH3HCXOH
KH raoxKH. npeflpacnonararomHMH 4>aKxopaMH aBJMioxca flJiHxejibHoe HapyuieHHC Hocosoro flwxaHHa, KypeHHe, Hacxwc nepeoxnaameHHfl, sarasosaHHOCXb H
sanbiJieHHOCXb Bosayxa npoHsso^cxBeHHoro noMemeHHa. Hacxo XPOHHHCCKHH
4>apHHrHx pasBHBaexca na 4>OHe naxonorHH acejiyflOHHO-KHUieHHoro xpaxxa, MOHCBblflejIHXeJIbHOH H CepflCHHO-COCyflHCXOH CHCXCM npH H3JIH4HH XpOHHHCCKHX
onaroB THOHHOH HH^CKUHH B OOJIOCXH pxa H noca.
B
33BHCHMOCXH OX MOp(j)OJIOrHHeCKHX HSMeHCHMH CJIH3HCXOH OSOJIOHKH
FJIOXKH BblflCJiaiOX K3Xap3JIbHHH, FHnepXpo4)HHeCKHH, axpo4>HHeCKHH XpOHHHCCKHC (J)3pHHrHXbI. IIpH K3X3p3JIbHOM ^apHHFHXe CJ1H3HCX3H o6oJIOHKa 33CXOHHO
ranepeMHpOB3Ha, pyifyfyyzm OXCHHS, cocy^Bi noflc;iH3Hcxoro cjioa pacuiHpeHH,
Ha6;iK)flaexca noBwmeHHe ceKpeuHH CJIHSHCXHX acejies. rHnepxpo$HHecKHH <J>apHHFHx (onaroBbiH HJIH flHfJxjjysHbiH) xapaKxepH3yexcH paspacxaHHBM
ajibHoro CJioa CJIHSHCXOH rnoxKH'~ero MexaiuiasHeH. Bbipaacena
HH(J)HjibTpauHa noflCJiHSHcxoro CJioa. Ha saaneH CXCHKC TJIOXKH onpeaejiaroxca
Teivia VIII. SAEOJIEBAHMfl rilOTKM.
140
CKOiuieHHa yBejiHHCHHbix 4>ojuiHKyjioB, MOKjry SXHMH CKoruieHHaMH oGpasyioxca
xa>KH. HepejjKO Ha6jiio,iiaexca FHnepxpo(J>Ha GOKOBHX BajiHKOB FJIOXKH. Axpo<J>HHCCKHH <J>apHHFHT XapaKXCpHSyeXCH pC3KHM HCXOHHeHHBM CJIM3HCXOH oGoJIOHKH
FJIOXKH, nacxHHHOH flecKBaMaimeH anHxennajitHbix CJIOCB, B oxaenbHbix cny^aax — oporoBCHHCM noBepxHOCTHoro CJioa MHOFOCJIOHHOFO miocKoro annxejina
saflHCH CXCHKH FJioxKH. CjiH3HCxaa oGojiOHKa saflHCH CTCHKH FJioxKH npHoSpcxaex
xapaicxepHbiH «JiaKOBbiH» GJICCK, JICFKO paHHMa, Hepe^KO Ha HCH oxMenaioxca cyXHC FHOHHblC KOpKH.
BojibHwe xpoHHHecKHM (J>apHHFHxoM Mcajiyioxca na cyxocxb, nepiueHHC,
«KOMOK» B ropjie, noKauiJiHsaHHe. IlpH (JmpHHrocKonHH noMHMo yicasaHHbix HSMCHeHHH CJIH3HCXOH OGOJIOHKH H3CXO BbMBJiaCXCa CXCKaHHC HO SaflHCH CXCHKC
FJIOXKH CJIH3HCXO-FHOHHOFO OXflCJiaeMOFO H3 HOC3.
Jlevemie xpOHHHecKoro <J>apHHFHxa xpeSyer BoccxanoBJieHHa HOCOBOFO flbixaHHa, a xaicace oflHOBpeMCHHoro jienenHa HMeiomnxca 3a6oneBaHHH iKejjyaoiHo-KHineHHoro xpaKxa, cepaeMHo-cocyflHCxoH, 3H^OKpHHHOH CHCXCM. Sanpemaexca KypeHHe, HCKJiroiaioxca HS flnexw npoayicxbi, pasapaacaiomHe cjiHsncxyio
F^OXKH. Ha npOH3BOflCXBC HCoGxOflHMO CoGjHOflCHHC M6p HHflHBHjryaJIbHOH 33UIH-
xbi flbixaxejibHbix nyxeft. B MCCXHOM jienenHH Hcnojibsyiox xa6jiexnpoBaHHbie
opajibHwe aHXHcenxHKH, opouieHHC FJIOXKH anxHcenxHRaMH, HHrajiainni Kpynno^HcnepcHbix aaposojicH ne^eGHbix xpas, Macen 3BKajiHirra, qanHoro aepeBa H ap.
IlpH FHnepXpo4>HH 4)OJIJIHKynOB SaflHCH CXCHKH, SOKOBHX B3JIHKOB F^OXKH HCHOJIb-
syiox HX npnacHraHHe HHxpaxoM cepe6pa. IIInpoKO Hcnonbsyexca na
FJIOXKH 4>OHO(J)ope3 nponojiHca H aHXH6HoxHKOB, jiasepoxepanroi. Hpn
CKOM 4>apHHrHxe HaaHanaiox saKanbisaHHe B HOC Macnanoro pacxsopa BHxaMHHOB
E, A H Apyrnx MacnaHbix Kanenb. CnHSHCxyio FJIOXKH opoinaiox HOflco^epacamHMH
npenapaxaMH. HapeHxepaJibHo Hasnanaiox GnoreHHwe cxHMyjiaxopw. IlpH oGrnniH
cyxHX KopoK npoBOflax HHranauHH npoxeojiHXHnecKHx (JiepMenxoB.
OapHHFOMHKOS - XpOHHHeCKOC BOCnajICHHC CJIH3HCXOH FJIOXKH, BbI3BaHHOC
rpHStcoBOH MHKpo(J)iiopOH (CM. pnc. 12 FIpHJioxceHHa). HaH6onee nacxo <})apHHFOMHKO3 BbisbiBaiox FpnGKH pofla Candida, pesKe Bcxpenaexca acneprniuies, neHHUHJUIHH03, MyKopos. B noflaBJiaiomeM GonbiuHHCxse cjiynaeB MHKOS FJIOXKH
yKasbiBaex Ha flHcGaicxepHos KHuieHHHKa. Cnoco6cxByiox pa3BHXHio^agHHroM.HKosa fljiHxejibHoe npHMeneHHC anxnGnoxHROB, xpOHHHecKHH cxgecc, 3HflOKp_HHHbie saGojieaaHHa, 3a6ojieBaHHa^ppBl7^cenTHHecKHe cocxoaHHa. MHKOSH JIOPOpraHOB, H B HaCXHOCXH - 4>apHHFOMHKO3, OXHOCHXCa K OnHOpXyHHCXKHCCKHM
3a6oi[eBaHHaM GonbHbix BPW-HH^eKUHCH, 10 % nornGiuHx ox
HMCIOX KJiHHHKy KaHflHflosa. MHKOS FJIOXKH np_oaBJiaexca onaraMH
rnnepruiasHH anmenna, o6pa3OBaHHCM rpanyjieM, onaroB HCKposa na CHHSHCXOH
TJTOxlcHrHa He6Hbix MKHflalTHHaxTHnephjiasHa MOKCT npHHaxb xapaKxep nanHJiTioMaxosa. npHjfcaji,2H,gp^e_C2H3HcjaHrjipjri^
xoJicxbiM MraHCXHM nana
KapxHHa 4>apHHFOMHKO3a Bcxpenaexca jmiiib na <J)OHC
TOHSUJlJlOrEHHblE OCJlOXHEHUfl
141
o6mero cocxoaHHa 6ojibHoro, npH Bbipaacennbix HMMynojiorHHecKHx paccxpoficxBax. B o6biHHOH npaKXHKe KJiHHHKa MHKOsa flocxaxoHHO cxepxa. KaH^KWOs noJIOCXH pxa H FJIOXKH npoaBJiaexca HajiHHHCM na CJIHSHCXOH aecen, meK, He6nbix
flyHcicax MCJIKOFO 6eJiecoBaxoro nanexa, nanoMHHaioinero MaHHyto Kpyny. B
npeazjBepHH poxoBOH IIOJIOCXH HHor^a cKanjiHBaexca TBOpoxcHcxbifi 6enbiH najiex. Bo MHOFHX cjiynaax npH (j)apHHFOCKonHH BOBCC ne y^aexca BbiaBHXb KaKHX
Jin6o CHMnxoMOB. /JnarHos ycxanaBJiHBaexca no MHKpocKonHH HaxHBHoro npenapaxa. MexajuiHHecKHM HHCxpyMenxoM (yiiiHOH JIOHCKOH OonbRMana, yuiHOH
nexjieK HJIH uinaxejieivi) npoaoflnxca cocKoS co CJIHSHCXOH na npe^MexHoe CXCKJIO, npH MHKpOCKOnHH KOXOpOFO BbiaBJMIOXCa BCC 3JieMCHXbI IpnGKOB.
B J16H6HUU HCo6xOflHMO HCnOJIbSOBaHHC CHCXCMHblX npOXHBOFpHSKOBblX npC-
napaxoB (^JIIOMHKOH, OpOHasoji, Hnsopaji H x. a.), aHTHFHCxaMHHHHx cpeflcxs. Hs
flnexbi 6onbHbix HCKjnonaioxca JICFKHC yrncBOflbi, peKOMCH^yexca uiHpoKoe HCnoJib3OBaHHe KHCJIOMOJIOHHHX npoayKXOB. DpOBO^HXca KoppeKuna flHcSaicxepnosa. MCCXHO Hasnaqaiox nojiocKaHne POXOBOH nonocxH H FJIOXKH KHC^HMH
pacxBopaMH (3 % pacxsopOM yKcycnoH, JIHMOHHOH KHCJIOX), ixo cnoco6cxByex
Bbipa6oxKe mejiOHHOH CJIIOHH, paccacbiBaHHe HJIH nojiocKaHHe FJIOXKH aHxncenXHK3MH c npoxHBorpHSKOBOH aKXHBHOcxbio — pacxBop AM(})oxepHUHHa B, MajiaBHxa, AKBHpHHa, xa6;iexKH CenxoJiexe, JleBopHH, HMyaon. CjiH3Hcxyro FJIOXKH
o6pa6axbiBaiox pacxBopoM xexpaGopaxa naxpna, KpacHxenaMH (MexHJieHOBOH CHHbio, (JiyKCHHOM). Us ^H3Honpoueflyp peKOMcuayiox YOO FJIOXKH, jiasepnoe ocBCHHBaHHe MHHflajIHH. 3(J)(j)eKXHBHOCXb JieiCHHa 4>apHHFOMHKO3a BblCOKa JIHIIIb
npn nosepxHocxHOM MHKOse npH ycneiiiHOH KoppeKUHH aHc6aicrepHO3a. B ocxajibHbix cjiynaax npnGeraiox K noBxopHHM KypcaM jienenHa. HepeflKO anHxejibHbie xypcbi JieMCHHa see »ce MajionepcnetcxHBHbi.
AnrHHa — o6mee HH(J)eKUHOHHoe saGojieBanne c MecxnbiMH npoaBJicHHaMH B
Bnae ocxporo BocnaneHHa oflHoro HJIH HecKOjn>Knx KOMnonenxoB JiHM<})afleHOHflHoro
FJIOXOHHOFO KOJibqa, name BCCFO HeGnbix MHHflajiHH (CM. pnc. 13
CpeflH pa3Hoo6pa3Hbix BOSMOHCHWX MHKpo6Hbix
KOKKOB, najIOHCK, BHpyCOB, CHHpOXCX, FpnGOB H Up. - OCHOBHaa 3XHOJIOFHHeCKaa
ponb npHHajirte>KHX 6exa-reMOJiHXHHecKOMy cxpenxoKOKKy rpynnu A. 3xox BO36yb, no aanHbiM pajja aaxopOB, o6Hapy5KHBaerca npn aHrnne B 30-50 % cjryy flexeii H B 15-30 % cjiynaea y aspocjibix. K nacxbiM sosGy/iHxejiaM
cjieiryex oxnecxH xaicace sojioxncxbifi cxa(J)HJioKOKK, sejienamnH cxpenxoKOKK
MeHxapHbiii nyxb sapaJKCHHa). BHpycoJiorHHecioie H KJiHHHnecKHe
HOKasajiH, MXO aaeHOBHpycu xaicace Moryx Bbisbisaxb pasuHHHbie 4>opMbi
KOXOpblC (J)apHHFOCKOnHHeCKH HeOXJIHHHMbI OX MHKpoGHblX aHFHH.
TOH3MJU1MTOB HO M. B. COJlflATOBY (1975)
Ocxpbie TOH3MJ1J1MTbl (aHTHHbl)
1 . TlepeuHHbie: KaxapanbHbie, jiaKynapHbie, 4>oJiJiHKyjiapHbie,
Tewa VIII. 3A6OJ1EBAHHH r/lOTKH.
142
143
JlaKyuapnaH aHrnna oxjiniaexcs ox 4>ojuiHKyjiapHOH XCM, HXO Ha nosepx-
2. BmopmHbie:
a) npH ocrpbix HH(J)eKH,HOHHbix 3a6ojieBaHHax — .zjHcjjxepHH, cicapJiaxHHe, xyJiapCMHH, 6ptOUIHOM XH(J>e;
6) npH saGoJieBaHHax CHCTCMH KpOBH — HH^CKUHOHHOM MOHOHyioieose, arpanyjiouHTose, neftKOsax, ajiHMCHxapHo-xoKCHHecKOH
XpOHMMeCKMM TOH3MJ1J1MT
1 . HecneiftKpmecKuu:
npH HH4>eKUHOHHbix rpanyjieMax — xy6epKyjie3, CKJIB-
, CH(J)HJIHC.
aHFHHbi npoHCxo/jHx no THiry ajuieprHHecKH-FHnepepFHHecKOH
, HTO asjiaexca npeanocbuiKOH ana BOSHHKHOBCHHa nocjie anrnHbi xaicnx
OCJIOSCHCHHH K3K peBM3XH3M, OCTpblH flH(}>4>y3HbIH HC(J)pHT H XpyTUX
3a6ojI6Ba-
HHH, HMCKMUHX HHCjjeKUHOHHO-aJUiepFHHeCKHH XapaKXCp. IIO JIOKajIH3aUHH BOC-
nanHxenbHoro npoqecca B npeflejiax FJIOXOHHOFO jiriM<J)OHflHoro KOntqa BaJibaeepa-IlHporoBa pasitHnaiox anrHHy asbiHHOH, HOCOFJIOXOHHOH MmmajiHH, ropxaHHyio H aHFHHy GOKOBHX BanHKOB FJIOXKH.
KarapajibHan anrHHa xapaKxeprayexca ocxpbiM HanajiOM, 03Ho6oM, GOJIHMH
B ropjie npH raoxanHH. He6Hbie MHnzjanHHW rHnepeMMposaHbi H oxe^Hbi, uieHHwe
peraoHapHbie jiHM(})aTHHecKne ysjiw (pacnojioxceHHbie no nepe/ineMy Kparo KHBaTenbHwx Mbiuiu na ypoBHe yr^oB HHXCHCH HCJIIOCXH) yBejiHHCHbi, IUIOXHM H 6ojie3neHHbi. Ha6jiJOflaexca noBwmeHHe reMnepaxypbi flo 38-38,5 °C. KaxapaubHoe
BocnajieHHe He6Hbix MHHflajiHH name npeacxaBJiaex co6oH HananbHyK)
(JxxruiHKyjiHpHOH H naKyHapHOM aHFHHbi HJIH flBJiaercfl cneflcxBHCM
HHX npoueccoB B HOCOFJIOXKC, Kopne asbiKa, ropxaHH, a xaicace CHMnxoMOM o6mnx
HH(J)eKaHOHHbix 3a6ojieBaHHH. JlflWTca KaiapajibHaa aHFHHa 1 -2 JUM.
IlpeHMymecxBeHHaa JiOKajinsamw BOcnajiHxeJibHoro npoqecca B o6;iacxH
MHHflanHH oxjiHnaex KarapanbHyio anrHHy ox ocxporo Kaxapa aepxHHx flbixaxenbHwx nyxeH, rpHnna, ocxporo H xpoHHHCCKoro 4>apHHFHxa. IIpn 4>apHHFOCKOHHH OTMenaexca Hpnaa rnnepeMHa MHHflajiHH Ha oxnocHxeJibHo SjieflHOM <J>OHe
CJIH3HCXOH 060JIOHKH HcGHblX HyXSK, 3aflH6H CXCHKH FJIOXKH.
OojuiHKyjiHpHaa aiiniHa npoxeKaex 5ojiee xocejio. TeMnepaxypHaa peaicmia
aocxuraex 38-39 °C, oxMenaexca 03Ho6, oiirymeHHe «JioMoxbi» B noaciorfflOH o6nacXH, B cycraBax pyn H HOF; GOJIH npH raoxaHHH pesKO BbipaaceHbi. Ha6.ino,aaexcH pesKaa
nmepeMiw H oxeHHocxb neGnbix MHH^ainiH, noa BOcnaneHHoK CJDOHCXOH Bnmn>i na4>oJuiHKyjibi B Bime 6enoBaxo->KenxoBaxbix xpyrjibix Bbmyioibix XOHCK
OKOHO 2 MM. PeraoHapHbie iiieHHbie jraM^axunecKHe ysjibi pe3KO 6ojiesHCHHH, yBenHMCHbi, nnoxHbie. FIpofloiracHTejibHOCxb saSojieBaHHa 5-7 flHefl.
IlpH HCCJICflOBaHHH KpOBH OXMCHaeXCfl JICHKOIIHX03 C HeHTpO^HJIbHblM CflBH-
FOM BneBo. Hacxo HMeHDx Mecxo npH3H3KH nopaHceHHa noHCK —
MHKporeMaxypHfl.
HOCXH BOCnaJlCHHblX MHHflajIHH BHAHW 5KeJIXOBaTO-6ejIbIC, JICFKO CKHMaiOmHCCa
Hanexw, pacnojioaceHHbie no xofly naKyn.
y HeKOxopwx 6onbHbix »cenxoBaxo-6eJibie Hanexbi BHXOZWX flajiexo 33 npeJiaicyH H noKpwBarox BCIO nosepxHOCxb MHHflajiHH, Kax npn ^H(})xepHH.
3XH cmiOEiHbie, (J)H6pHH03Hbie Hanexbi HHKoraa HC pacnpocxpanaioxca 33
JiHH H npn HX CH^THH (Hnor^a c xpyziOM) nosepxHocxb MHnaajiHH
H6 KpOBOXOHHX.
a)
2. CneifutputecKuit:
TOHSHJinorEHHblE
njieHMaraH anraHa (anrnna CHMaHOBCKoro-BeHcaHa-ITjiayxa, <J>yBbisbiBaexca CHMGHOSOM cnnpoxexbi HOJIOCXH pxa H BepexeHoo6nanoHKH. SaGojieaaHHe peflKo HMCCX ocxpoe nanajio, name pasBHBaexca
^BOJib. TeMnepaxypa xena o6biHHO cy6(j)e6pHJibHaa, 6ojiH B ropJIC He3H3HHXeJIbHbI, 6ojIbHbIX H OKpyHCaiOIUHX 6eCnOKOHX, FJiaBHblM o6pa3OM, OX-
BpaTHxenbHbiH sanax HSO pxa. IIpn 4>apHHrocKonHH cjinsncxaa sesa HMCCX oGbinHyro OKpacKy, oana H3 MHH^ajiHH ysejiHneHa, ranepeMHpoBaHa, na ee nosepxHOCXH HMeexca r;iy6oKaa assa c HCPOBHWMH KpaaMH H ^HOM, sanojmeHHaa XKaneBHM aexpnxoM, KoxopbiH jierKo yflanaexca. AnajiorHnHbie asaw Moryr BOSHHKHyxt na MarKOM ne6e H B HOJIOCTH pxa.
PerHonapHbie JiHMcJiaTHHecKHe ysjiw, oco6enHo na cropone nopaaceHHa, ysennHeHbi, nnoxHbi, 6e36oJie3HeHHbi. Flpn GaKxepHocKonHnecKOM HccJieflosanHH
Hanexa HJIH ox^ejiaeMoro assbi oGnapyxcHBaioxca Fusobacterium fusiforme H
Spir. Vincentii. HsMCHCHHa cocxasa KPOBH oGbiino sajonoHaroxca B yMepennoM
jieiiKOUHxose, aHCMHH, yBejiHHCHHH CO3.
KpOMe nopajKCHHa HeGnbix MHHflariHH Ha6;iK)aaexca anrnna HOCOFJIOXOHHOH
MHHflanHHbi — ocrpbiB aaenoH^HT. SaSoJiesaHHe nanHHaexca ocxpo c noflieMa
xeMnepaxypbi, O3Ho6a, 6oJieH B ropjie, FOJIOBHUX GOJICH, sajioxcenHocxH noca,
noaBJICHHa CJIHSHCXO-FHOHHblX BblflCJieHHH H3 HOC3. IlpH (JjapHHFOCKOnHH CJIH3H-
cxaa o6ojiOHKa saflHeft cxemcH FJIOXKH rnnepeMHpoBaHa, BH^HH CJIHSHCXOFHOHHbie BbiaejieHHa, cnycKaromHeca H3-33 HeSnoH saHasecKH. TaKaa KJIHHHHCCKaa KapXHHa ^aex ocHosaHHa ^iw oniH6oHHOH anarHocxHKH OP3. B OXJIHHHC ox
OP3 (XKHHIHO BHpycHoii HH^CKUHH) npH ocxpoM aflenoH^Hxe meHHbie pernoHapnbie jiHMfJjaxHiecKHe ysjibi snaHHTejibHO yBejinneHbi, HJIOXHH H pe3KO 6ojie3HCHHbl. IlpH SaflHCH pHHOCKOHHH HOCOFJIOTOHHaa MHHflaJIHHa OXCHHa, FHnepeMH-
pOBana, B ee Soposaax H mejiax BHOTO CKOiuieHHe FHOHHOFO HJIH CJIHSHCXOFHOHHOFO ceKpexa; nepe^KO HMeroxca HSMeneHHa, xapaKxepHbie fljia ^toiuiHKyJiapHOH, JiaKyHapHOH HJIH 4>H6pHHO3HOH aHFHHbl.
FIpH nepeaneH pHHOCKonHH onpeaejiaioxca rnnepeMHa H OXCK CJIHSHCXOH
HOCa, CJIH3HCXO-FHOHHbie BblflejICHHa, npeHMymeCXB6HHO B 33AHHX OX-
Hoca. HOCOBOC flbixaHne pe3KO saxpy^neHO. V aexen cHMnxoMbi ocxporo
Moryx Hnorfla npejjmecxBOBaxb KJIHHHHCCKOH KapxHHe o6mnx HHa6oneBaHHH (HH(J)eKLi;HOHHbiH MOHOHyKJieos, Kopb, Kpacnyxa,
CKapJI3XHH3, KOKJUOIH, nOJIHOMHCJIHx).
144
Teiua VIII. SAEOJIEBAHMfl rilOTKM.
TOHSMnjnOrEHHblE OCDOKHEHUfl
AHPHHa H3UHHOH MHHJjajIHHbl. IIpHHHHOH 3XOFO SaGoJICBaHHa aBJMCXCa
4. fljia aH(JpxepHH xapaKTepHbi njioxnbie nepJiaMyxpOBO-cepbie (HHorjj,a rpasHO-cepue, acejixoBaxbie, KopHHHeBaxbie, sejieHosaxbie) Hanexbi na MHH^anHHax. B
nepsbie nacbi nocjie noaBneHHa nanexbi XOHKHC, JICFKO cHHMaroxca, HO Gwcxpo
BO3HHKaiox BHOBb, saxcM npeBpamaiOTCH B xojicxwe nueHKH, cnaanHbie c nofljie>KauiHMH XKaHJiMH H CHHMaiouj,Heca c xpyflOM. nocne HX yjjaneHHa ocxaexca 3po3HpoB3HHaa, KpoBoxonamaa nosepxHocxb. Hajiexw HMCIOX xenfleHUHio pacnpocxpanaxbca c MHHaajiHH na ^y>KKH, Mareoe ne6o, Kopenb asbiKa, ropxanb. Y/iajieHHbie JiH(j)xepHHHbie Hajiexw xonyx H HC pacxBOpaioxca B Boae, c xpyAOM pacxHpaioxca na npe^MexHOM cxeitne.
5. PerHonapHbie jiHM(j)axHHecKHe ysubi yMepeHHO (npn TOKCHHCCKOH jj,H(J)xePHH) HJIH pesKO yBejinneHbi, sjiacxHHHH, Maiio HJIH yMepeHHO 6ojie3H6HHbi, HCpeflKO coBepmeHHO 6e36ojie3HeHHbi npn najibnaunn.
6. TpH3M (x. e. saxpyflHeHHe npn oxKpbiBaHHH pxa) y 6ojibHbix ^H(j)xepHeH,
Kan npaBHJio, oxcyxcxByex jj,a>Ke npn oGmnpHOM nopaaceHHH MSFKHX XKanefi
FJIOXKH H men.
7. Jinn aH(})xepHH xapaKxepen napajuiejiHSM ivte^yiy BbipaacenHocxbio npouecca B raoxKe H cxenenbio oSmefi HHXOKCHKaijHH, Koxopaa xapaKxepnsyexca sajiocxbio, anaxneH, coHJiHBOCxbio 6oJibHoro, 6jiejiHocxbK) KO>KHbix noKpoBOB, oxe-
3KTHBH33H,Ha naxoreHHOH MHKpocjmopbi flbixaxejibHbix nyxeft, oflOHXoreHHaa HH4>eKUHa, HHOrfla
XpaBMHpOBaUHe JIHM(j)OHflHOH XK3HH KOpHfl a3HKa HHOpOJJ-
HHM XCJIOM. CjiH3Hcxaa saflHCH CXBHKH FJIOXKH, a HHoraa H HeGnwe MHimajiHHbi,
HecKOJibKO FHnepeMHpOBaHbi, npH FHno<j)apHHrocKonHH oxMeiaexca pesKaa FHnepCMHfl H OXCK JIHM<J)OI1HHOH XKaHH KOpIM 33bIKa, HCpCflKO BHflHbl HaFHOHBIIIHeCa <}>OJIJIHKyjIbI HJIH <J)H6pHHO3Hbie HOJieTbl Ha nOBCpXHOCXH H3HHHOH MHHflajIH-
Hbi. IIIeHHbie perHonapHtie JiHMiJ>axHiiecKHe ysjibi yBenHHenbi, ruioxHbi, pesno
6ojie3HCHHbi; GojiesneHHOCxb onpejiejiaexca xaiOKe npn rnyGoKOH najibnaiiHH nepeflHCH noBepxHOCTH BepxHero oxflejia men. AnrHHa aswHHOH MHHflajiHHbi MO5Kex ocjio>KHHTbca a6cueccoM Kopna asbina, (JwierMOHofi nua HOJIOCTH pxa HJIH
OXCKOM ropxaHH. Ilo3TOMy npn ycxaHOBJieHHH anarHosa BocnajieHna asbiHHOH
MHHAajiHHbi 6ojibHbie nofljieacax cpoHHoii rocnHxajiHsaqHH.
AHPHHE SOKOBBIX BEJIHKOB FJIOTKH npeacxaBJiaex coGoft BocnajieHHe JIHM4>OHflHOH XKaHH 3aflHe60KOBOH CX6HKH FJIOXKH, npHJieraiOUjeH K SaflHHM
145
fly»K3M.
3xa JiHM(})OHflHaa XKanb Hepe^KO noflsepraexca KOMnencaxopHOH rHnepxpo(J)HH y
JIHU, nepeHeciiiHx TOHSHJISKTOMHIO. Haiano saGojiesaHHa ocxpoe, noaBjiaerca
o3Ho6, noBbimaexca xeMnepaxypa no 38-39 °C. BojibHbie acajxyioxca na pesKne
GOJIH B ropjie, HppaflHHpyiomHe B yiiiH. Hapymaerca COH, annexnx, o6mee caMOnyBCXBHe, B03HHK3IOT GOJIH B cycxasax. Ilpn 4>apHHrocKOHHH na (})OHe ranepe-
KOM IIOAKTOKHOH KJieX43XKH UICH, HBJICHHaMH XOKCHHCCKOrO MHOKap^HXa, HHOF/ia
6OJWMH B >KHBOXe H pBOXOH.
MHH Sa^HCH CXCHKH FJIOXKH OXMCiaCXCa pe3K3a HH(J)HJIbXpaUHa 60KOBbIX B3J1H-
Jlenenue nepemnux amun. BojibHbie KaxapajibHOH, JiaKynapHOH H <J)OJiJiHKyjiapHOH anrHHOH o6biHHO npoxojigx neneHHe 3M6yji3xopHO no^ Ha6niofleHHeM
xepaneBxa HJIH B HH(J>eKUHOHHOM cxauHonape.
B nepBbie ^HH 3a6ojieB3HHa peKOMeHayiox co6jnoaaxb nocxeJibHbiH pe^HM,
no yjiynmeHHio cocxoflHHH — AOMauiHHH HJIH najiaxHbiH. BCCM 6oJibHbiM anrn-
KOB, BHflHH HarnoHBiiiHeca 4)oiuiHKyjibi. UleHHbie peraoHapHbie jiHM^axHiecKHe
ysjibi yBejiHHCHbi, IUIOXHW, SojiesneHHbi. 3a6ojieBaHHe npoaoji»caexca 3-4 ^HH.
BxopHHHbie anrHHw noapoGno paccMaxpHBaioxca B icypce HHc|)eKi(HOHHbix
6ojie3HCH, reMaxojiorHH. YHHXbiBaa He6jiaronpHaxHyio 3nHfleMHiecKyio o6cxaHOBKy no flH<j)xepHH H onacHocxb ^aHHoro 3a6ojieBanHa, Heo6xoflHMO noMHHTb
cjieflyromne npHsnaKH ^H^xepHH, oxjiHiaroume ee ox apyrnx ocxpbix BOcnajiHxejibHbix 3a6ojieBaHHH FJIOXKH:
1. BOJIH B ropjie npn jjHiJixepHH cjia6o HJIH yMepeHHO Bbipa»ceHbi (x. K. flH<j}xepHHHbiH XOKCHH oGjia^aex aHaiibresHpyioniHM jencxBHeM) H Moryx COBCCM oxcyxcxBOBaxb. SaxpyaneHHe raoxanHa npn flH^repHH oGycJioBJieno ne cxojibKO
HOH npOHSBOJiaX o6lIIHH aHaJIH3 KpOBH H 3H3JIH3 MOHH, npH H3JIHHHH FHOHHOH
anrHHbi, OCJIOJKHCHHH aHFHHbi — nocea CJIHSH HJIH najiexa c MHHflanHH JIJIH HCKJHOHCHHa JIH(})XepHH.
flnexa ^on>KH3 6wxb JierKoycB3HB3CMOH, npeHMymecxBCHHO MOJIOHHOpacxHxeJibHOH, 6oraxoH BHxaMHHaMH, oco6eHHO C H rpynnw B. Run
CHKaiiHH peKOMCHJiyexca o6HJibHoe nwxbe. OpenapaxaiviH Bbi6opa juia
aHFHH aBJiaroxca nojiycHHxexHHCCKHe neHHUHJUiHHbi, ue<f>ajiocnopHHbi I noKOJieHHa, npenapaxaMH pesepsa — MaKpojiHflbi (asHxpoKC, pyjina, poBaMHUHH). Jle-
6oJIbK), CKOJIbKO OX6KOM MaFKHX XKaHCH TJIOXKH.
2. HajiHHHe oxexa MarKHx xKaneH TJIOXKH H men aBJiaexca xnnHHHbiM CHMnxoMOM flH^xepHH. KojKHbie noicpoBbi men HMCIOX o6wHHyio onpacKy; ^aBJieHHe
B oSnacxH oxena 6e36ojie3HeHHo H HC ocxasjiaex aMOK; npn xojiHKoo6pa3HOM
yaape najibueM oxennbie xxaHH coxpacaioxca HanofloGne Hcene HJIH cxyana. OXCK
Moacex pacnpocxpanaxbca na JIHUO ao CKyjiOBofi pyni H cocueBHanoro oxpocxKa,
na meio, rpy/jHyio miexKy.
3. CjiHSHcxaa o6ojioHKa sesa nepesKO HJIH yMepenno rHnepeMnpOBana: sona
rnnepeMHH orpaHHHena H HMeex UHaHOXHHHbiH, 3acxoHHWH oxxenoK; cjinsncxaa
HCHHe aHXH6HOXHK3MH ^OJDKHO COnpOBO)KflaXbCa KOppeKH
npoxHBOBOcnajiHxejibHaa xepanna npHMenaexca npn rnnepeprHHecKOH
opraHHSMa (xepa-4>jno, napaiiexaMon, xafijieHOJi, acnnpHH). C uejibio
Mexa6oJiH3Ma, pa6oxbi (J)epMeHXHbix CHCXCM, yMCHbiiieHH
AencxBHa CBo6oaHbix pa^HKanoB H nepeKHCHbix coeaHHeHHH, noBbiuieHHa HMMyHHxexa naaHanaiox aHXHOKCH^anxbi (pyxHHCOjiep^camHe KOMnjieKCbi, BHxaMHHbi A, E, C, MHKpo3JieM6HXbi Zn, Mg, Si, Ca, ciuiax-KJiaMHH). Mecxno
nojiocKaHHe ropna pacxsopOM 4>ypaiiHJiJiHHa, nepManranaxa Kajina,
cojieBbiM pacxBOpoM, oxsapaMH jieKapcxBeHHbix xpaB. Xopomo
o6ojIOHKa 3CB3 npH JIOKajIH3OBaHHbIX 4>OpMaX flHCJlXepHH MOHCCX HMCXb H o6bIH-
OKpacKy.
k
146
TeMa VIII. 3AEOJ1EBAHMH fTIOTKH
ce6a a3p03OJii>HbiH aHXH6HOXHK «BHonapoKc» — no 4 HHrajiauHH 4 pasa B ^enb B
xeqeHHe 5-7/BUCK. Ilpn npoxHBonoicasaHHax K aHXHSnoxHRoxepanHH PCKOMCHJiyexca npHMCHaxb aaposojra (,D,HOKCH3OJib, HnranHnx, KaiwexoH) 4 pasa B cyxKH
B xeneHHe 5-7flHefi (npenapax Hanocax noonepeaHo Ha npasyio H jiesyio ne6Hbie MHH/iajiHHbi). Hasnanaiox opaJibHbie aHxncenxHKH — OajiHMHHx, OapHnrocenx, Cenxojiexe, FeKcajiHS, CxpencHJic B BHUC samenHbix xa6nexoK (no 3-5
xa6nexoK B ^ent B xeieHHe 3-5 AHCM).
HeijeJiecooSpasHbi Karate 6bi xo HH 6bino CMasbiBaHiw MHnaanHH. HCKJUOHCHHCM aBJiaexca asBeHHO-ruieHHaxaa aHrnna CHMaHOBCKoro-BeHcaHa-Ilnayxa, npn KOXOpOH, KpOMC BHyTpHMbfflieHHblX HHICKUHH MHapCCHOJia HJIH aHXH6HOXHKOB HCHH-
UHJijiHHOBoro paaa, npoH3Bo,oax cwtasbiBaHHe asseHHbix nosepxHocxeH nopa^ceHHbix
ynacxKOB 10 % pacxsopOM HOBapcenojia B nniuepHHe HUH pacxsopoM 6eH3HjuineHHHHJXJIHH3 10000 Eff, B 1 MJl aHCTHJIJIHpOBaHHOH BO/lbl
XpOHHHCCKHH HecneilH(j)HHeCKHH TOH3HJIJIHT
2 pa33 B flCHb.
o6mee HH(J>eKUHOHHO-
ajuieprHiecKoe 3a6oJieBaHHe c MCCXHWMH npoaBJieHHaMH B BH^C CTOHKOH BocnajiHxeJibHOH peaKHHH neGHbix MHHflanHH, MOp(})ojiorHHecKH Bbipaacajomnxca B BHae arrbxepauHH, 3KCcy^aqHH H npojiH^epaqHH. OopMHpOBaHHio xpOHnnecKoro
xoHSHjiiiHxa cnoco6cxByiox HapyuieHHHH apena^K naxyH MHHaajiHH, HMMynnwe
HapyuieHHa, nacxbie BOcnajiHxejibHbie 3a6oJieBaHHa aepxHHX jbixaxentHbix nyXCH, cxoiiKoe HapyuiCHHe HOCOBOFO flbixaHHa, KypeHHe H x. #.
XpOHHHecKHH XOH3HJMHX ycyrySnaex HMeromneca HMMyHOJiorHnecKHe napymeHHa, HXO oco6eHHO apKO npoaBJiaexca B /JCXCKOM sospacxe. Y flexefl B Bospacxe
l,5-3jiex KnexoiHbiH cocxaB MHH^anHH Ha 80% npe^cxaBjien T-itnexKaMH. B
3XOM Bospacxe HMeroxca <J)H3HOJiorHHecKHe oco6eHHocxH B OXHOIUCHHH cy6nonyjiaqHH T-jiHM(J)oqHXOB c aegocxaxKOM T-xemiepoB, TTO npHBOflHX K HeaocxaxoHHOCXH KJiexoHHoro 3Bena HMMyHHxexa H o&bacnaex npeBanHpoBaHHe BHpycHOH, ipn6KOBOH H ycjioBHO-naxoreHHOH MHKpo(j)Jiopbi B naxojiomH nHM(J)orjioxoHHoro KOjn>u;a.
He^ocxaxoK T-xennepOB npHBO^HT xaiMce K nea^eKBaxHOH ,zoi4><J)epeHiiHpOBKe
B-jmM(J)OUHxoB H npH HOBbiiiieHHOH aHXHTCHHOH Harpy3Ke Bbisbisaex nmqOTpoflyKujno HMMyHorao6yjiHHOB icnacca E, a HC KJiacca A B JDCVK^OHOHOH xKaHH, HXO o6yHH(j)eKUHOHHo-anjiq)raHecKHH naxorenes xpoHHnecKoro xoHSHmmxa. HexpoHHMecKHH XOH3HJUIHX B axoM Bospacxc coHexaexcH c KOHCHbiMH ajuieprHMeCKHMH 3a6oJI6BaHHaMH, 6pOHXIEUlbHOH aCXMOH. HH3Kaa CnOCoSHOCXB JIHM(j)OHflHOH
TK3HH K CHHxesy nojiHOueHHbix aHXHxeji Be^ex K ranq)njia3HH He6HbK H raoxoiHOH
MHHflanHH. IlySepxaxHbiM nepnofl, xapaKrepHsyerca yMCHbrneHHeM Maccw jmM(J)OHflHBK opranoB, SypnoH cxHMyjiauHeft ryMOpajibHoro SBena HMMyrarrexa. 3xo seaex B
cjiynaax K ocJiaSneHHio xajicecxH axHrmnecKHx GojiesHen, B ^pyrax — K conpaayxoHMMyHHbiM 3a5o^eBaHnaM. B nocjie^Hne ro^bi oxMeiaerca, HXO npn ^eKOMneHcauHH xpOHmecKoro xoH3HJuiHra yraexaexca aexoKCHKaiwoHHaa (JiymcuHa neHCHH 33 cnex yrHexeHHa pexHKyjioararrejiHajibHOH, MOHooKCHreHasHOH CHCXBM neieHH.
HanSojiee aocxoBepHbiMH npnsHaKaMH xpOHHHCCKoro xoHSHJMHxa aBjiaioxca:
1) rnnepeMHa H BajiHKOo6pa3Hoe yxojimeHHe Kpaes neSHbix syyKQK',
TOHSHJlJIOrEHHblE OCJ1O>KHEHH«
147
2) py6iiOBbie cnaiiKH MOitay MHHflanHHaMH H He6HbiMn .nyacicaMH;
3) paspwxJieHHbie HJIH py6uoBO ynnoxHeHHbie MHHflajiHHbi;
4) KaseosHO-rHOHHbie npo6KH HJIH HHJIKHH FHOH B jiaKynax
5) yBejiHHCHHe saiejirocxHbix jiHM(J)oy3JiOB (peraoHapHbiH jiHM(J)aj;eHHx).
/JnarHOS xpOHHiecKoro xoHSHJUinxa ycxaHaBJiHBaiox, CCJIH HMeexca asa H
6ojiee MCCXHblX npH3H3K3 XOH3HJUIHX3.
ripH KOMneHCHpOB3HHOM XpOHHHCCKOM XOH3HJIJIHXC HMCIOXCa MCCXHWC npH-
3H3KH xpOHMHecKoro BOcnaJieHHa neSHbix MHHflajiHH. BapbepH3a 4>yHKqHa MHHaanHH H peaKXHBHocxb oprannsMa ne napyuieHbi, B CBasn c HCM o6mefi peaicu,HH
opraHHSMa HC nacxynaex. ^Hamos <iame acero ycxaHaBJinsaexca npH npo4)HJiaKXHHCCKOM ocMoxpe, nauHeHXbi omymaiox ce6a npaicxHHecKH saopoBHMH JiioabMH. Haorfla HMeexca xcanoSa H3 HenpHaxHHH 33H3X HSO pxa.
flpH fleKOMneHcauHH xpOHHHecKoro TOHSHJiJiHxa noaBJiaexca o6maa pe3Ki;Ha
opraHHSMa B BHJJC o6meHHXOKCHKaqHOHHoro CHHjjpoMa — ffUHxejibHOH cy6(J>e6PHJIBHOH JIHXOp3flKH, CHHJKCHHa aHHCXHXa, nOBblUICHHOH JTOMJiaCMOCXH H X. fl.,
anrHH, peuHflHBOB napaxoH3HJUiapHbix H rjioxoHHbix a6cqeccoB, pas3a6ojieB3HHH oxflaneHHbix opranoB H CHCXCM, naxorenes Koxopwx conpa3K6H c xpoHHnecKHM XOH3HJUIHXOM (peBMaxH3M, rjiOMepyjiOHe(j)pHX, apxponaxHH,
KapflHonaxHH, THpeoxoKCHKoa, HH(J)eKUHOHHo-3aBHCHMaa SpOHXHajibHaa acxiwa).
Jlevemie xpoHHHCCKoro HecneiiH(J)HHecKoro xoHSHJWHxa KOHcepBaxHBHoe H
onepaxHBHoe. KoHcepBaxHBHOMy jieneHHio nofljieacax XPOHHHCCKHH KOMnencHpOBaHHHH XOH3HJIJIHX H
flCKOMneHCHpOBaHHWH
XOH3HJIJIHX, npOaBJMK)UJlHHCa
XOHSHJUIorCHHOH HHXOKCHKaaHCH H pCUHflKBaMH 3HFHH. ^pyfHC HpOSBJieHHa flC-
KOMneHcauHH yKasbisaiox na neo6xo;iHMocxb onepaxHBHOro JieneHHa xpOHHHeCKOFO XOH3HJUIHXa.
KOHCepBaXHBHOM JICieHHH XOHSHJIJIHXa HCHOJlbSyiOX npOMblBaHHC JiaKyH
MHHflMHH H nOJIOCKaHHC TJIOXKH p3CXBOp3MH aHTHCCnXHKOB (MOJiaEHX,
, oKxeHHcenx, xjiopreKCHflHH), BBefleHHe aHXH6aKxepHa^bHbix npenapaxoB, osoHHpoBaHHbix pacxBopos B HeGnbie MHH^aJiHHW nyxcM (})OHO(})ope3a,
psccacbmaHHe opajibHbix aHxncenxHKOB (cenxoJiexe, anxHanrHH, ce, cxpencHJic). V flexen cxapme 6 Jiex H sspocjibix nposoaax jieneHHe xpoHHiecKoro XOH3HJMHX3 Ha annapaxe «ToH3Hjuiop», KoxopwH conexaex yjibxpaSByKOBoe BosaeiicxBHe Ha xxanb MHH^anHHbi, acnnpaqHio naxojiorHHCCKoro cojepacHMoro H opomeHHe aHXHcenxHHecKHM pacxBopoM. HasHansexca Jissepoxepanna Ha o6jiacxb MHH^ajiHH, MarHHxoxepanna na o6nacxb pernonapHbix JIHM4>oy3JiOB. BojibHbiM peKOMCHayiox npn Heo6xoflHMOcxH npoBCCXH eaHaqHK) sy6oB, nojiocxH Hoca H OKOJIOHOCOBHX nasyx, KoppeKUHio HOCOBOFO ^bixaHHa. B
KOMnjieKc jieneHHa BKJHOiaiox HMMyHocxHMyjiHpyiomyio xepsnHK).
H3 coBpeMCHHbix HMMynocxHMyjiaxopOB npe^noMxeHHe cjieayex oraaBaxb anXHreHHbiM jiHnonoJiHcaxapHaaM MHKpo6Horo npOHCxosiyieHHa (pnGoMynHJi, 6pOHxoMynaji, GecxaxHH, nacnax), jiH3ax3M GaicxepHH (HMyflOH, HPC-19), nenxH^aiw c
HMMyHoperyjinpyioiuHM, renaxonpoxeKxopHbiM, aHXHOKCH^aHTHbiM
TeMa VIII. SAEOflEBAHMfl TJIOTKH.
148
(HMyHO(})aH, HOJIHOKCIiaOHHH), npHpOAHblM HMMyHHOMO/TyJIHpyiOmHM
(KCHb-UieHb, JICB3ea, 3XHH3qea, HCCHOK, npOHOJIHC, IiaHTOKpHH, HHCTOTCJI, pOM3LU-
Ka, «HMyHaji»). KypcaMH HasHanaiOT roMeonaxHHecKHe cpe,ncxB3 (xoHSHJinoxpeH,
xoHSHJibroH, xoiBHJLJioxejib, 3y(J)op6HyM). EojibHHX XPOHHHBCKHM XOHSHJIJIHXOM
noflne>Kax nocxanoBKe Ha aHcnaHcepHHH ynex oxopHHOJiapHHrojiora.
H,ejib xHpyprHHecKoro jiCHCHHa — nojmoe y/janeHHe onara XPOHHHCCKOH
HH(J>eKUHH. B nacxoaiuee BpeMa onncaHbi paanbie cnoco6bi y^ajieHHS He6Hbix
MHHaajiHH (c noMombio XHpyprHiecKoro Jiaaepa, KpHOflecxpyKuna' H ap.), HO
uiHpOKoro npHMeneHHa SXH Mexoflbi HC naiujiH, H HaH6onee pacnpocxpaneHHbiM
cnoco6oM ocxaexca KJiaccnnecKaa ^BycxopoHHxa xoHSHJUisicxoMHa. Hoa MCCXHOH
3Hecxe3HCH MHHjjajiHKOBbie HHIIIH HH(j)HJibxpHpyK)xca paciBopOM HOBOKaHna.
He6naa MHH^ajiHHa <J)HKCHpyexcfl Ha uamcy. Ha nepeflHCH neOnon ay>KKe y
BepxHero nonioca MHHflanHHbi, napamiejibHO Kparo He6HOH jiyxKM npoBojxax
CJIHSHCXOH o5onoHKH, pacnaxopoM BbicBo6oHyiaexca BepxnuH nonioc
ajiee xynbiM nyxeM (xyn<J)epOM HJIH MHHaanHKOBOH JIO>KKOH) SKCXpaKancynapHO MHH^ajiHHy Bbwejiarox H3 HHIIIH. CioiaflKy Tncca pacceKaiox. OxMHHflanHHbi npOBO^ax nexnefi Baxona. AHanornHHO y^ajiaexca neGnaa
npoxHBonojio»(HOH cxopOHbi. B nocneonepauHOHHOM nepnoae peKOmaaamyio flHexy, nonocKaHHC TJIOXKH oxaapoM jieqeGnbix xpaa, opornoxKH cnpeeM «BHonapOKC», paccacwBaHHe opanbHbix anxHxcenxHKOB.
B xeneHHC Mecaua peKOMCHflyexca orpaHKHCHHe (J)H3H4ecKOH
MecTHbie n
TOHSunnoreHHbie
xoHSHiuioreHHbix OCJIOWHCHMH HanGoJibiuee npaKXHHecicoe
HMCIOX a6cueccbi FJIOXKH. BojibHbie napaxoH3HiuiHXOM, napaxoHSHiuiapHbiM, napa<J)apHHreajibHbiM aOcueccaMH cocxaBJiarox 6ojibuiHHCXBO cpe^H naunenxoB,
o6paxHBiiiHxca B cxaunoHap sa OKasaHHeM 3KcxpeHHOH HOMOIUH. ToH3HiuioreHMe^HacxHHHx, xoH3HjuioreHHbiH cencHc BcxpcHaioxca 3HaHHxenbHO pexce,
cocxojiHHa xpe6yK)x cuoacHbix onepaxHBHbix BMeuiaxenbcxB
MeaHacxHHOxoMHH npH MeflHacxHHHxe, XOH3HJUI3KXOMHH c nepCBas-
TOHSHJinorEHHblE OCJIOKHEHU?)
149
(J)apHHrocKonHH BbiaBJiaexca acHMMexpna aesa, BOcnajinxejibHaa HH<j)HjibxpauHa
HeSnbix pyiKeK, CMemeHne OJJHOH H3 MHHjjajiHH, yBejinneHHe H 6one3HeHHocxb
uieHHbix perHonapHbix jiHM<j)axHHecKHx ysnos, xpnsM. Bbipaxcen o6meHH(J)eKi;HOHHbiH cHH^poM: noBbiiiieHHe xeMoepaxypbi xena, BocnajinxejibHbie HSMeneHHa
co cxopOHbi KpoBH. JlevemiB — BCKpbixne a6cuecca B Mecxe HaHGojibiuero Bbi6yX3HHX HJIH B XHOHHHOM MCCX6.
IlaptupapumeajibHbiu adcuecc. BojibHbie acajiyioxca na peaKO
6onH B ropjie, ycHJiHBaiomHeca npn rjioxaHHH, HHor^a HapyiueHne
CJIIOHOXCHCHHC, HeBO3MO)KHOCXb HpOrjiaXblBaHHH 5KH/IKOH HHIUH, XpH3M HCCB3-
xejibHOH MycKyjiaxypw, BbiHyac^eHHoe nojioaceHHe rojiOBbi (naioioH B Sojibnyio
cxopony). XapaKxepHbi aBJienna HHXOKCHKaijHH: o6mee xa>KCJioe cocxoaHHe, BHcoKaa xeMnepaxypa, BHCOKHH JICHKOIIHXOS, yBejiHHCHHe CO3, c/iBHr 4>opiviyjibi
BJICBO. ITpH (J)apHHrocKonHH oxMenaexca saxpyflHCHHe oxKpbiBanHa pxa, o6jio5K6HHbIH a3bIK, THnepCMHa H OXCHHOCXb He6HbIX ffyiKCK, BbmaMHBaHHC 6OKOBOH
CXCHKH rjioxKH Ha cxopone nopa*:eHHa. OpH ocMoxpe onpe^ejiaexca acHMMexpna
men 33 cnex oxeKa H HH<J)HJibxpau,HH MarKHX XKanefi B o6n3CXH yrna HHMCHCH neJIIOCXH H 33iejIK)CXHOH HMKH; HpH n3JIbH3i;HH HH(J)HJIbXpaX lUIOXHblH, 6oJie3HCH-
Hbiii, 4>JiK>KxyaiiHH, KaK npaBHJio, onpe^eJinxb ne y^sexca. Hnor/ia HHCJmjibxpax
pacnpocxpanaexca BHHS no nepeflHeiny Kpaio KHBaxejibHOH Mbimubi.
napa<J)apHHreaJibHbiH aGcnecc nepeflKO ocno5KHaexca MeanacxHHHXOM, MCHHHFHXOM, XpOM6o30M KaBCpHOSHOFO CHHyCa, apCMHOH BCHH, CCHCHCOM, nO^HC-
JIIOCXHOH 4>JierMOHOH, rjiy6oKOH 4)JierMOHOH men, apposHBHbiM KpoBOxeneHHCM
H3 MarHcxpanbHbix cocy^OB men.
JleneHue. Ha (J)OHe npoxMBOBOcnajiHxejibHOH, HH^ysnoHHOH H HMMynoxepaHHH npoH3BOZ(Hxca cpOHHoe xHpyprHHecKoe BMeiiiaxeJibcxBO — BCKpbixne aGcijecca. BOKOBOH raoxoHHbiH aScqecc Moacno BCKpbixt ^Byna cnoco6aMH: nepes 6oKOByio cxeHKy TJIOXKH H napy^cHbiM ^ocxynoM. HapyacHbiH flocxyn ncnojibsyexca npn
pacnpocxpaHCHKH raoa a6cuecca no KJiexnaxoHHbiM npocxpancxBaM men (UICHHOH
<J)jierMOHe). ECJIH y 6ojibHoro c xoHSHJinoreHHbiM napatJtapHHreajibHbiM a6cqeccoM
BOSHHKaex apposHBHoe KpOBOxeneHHe, noKasanbi oSnaMceHHe ineHiioro cocyflHcxoro nyHKa, najioaceHHe npoBHSopHoii JiHraxypbi na o6myio coHHyro spxepnio, nepe-
KOH BHyXpeHHCH apeMHOH BCHbl HHXCC BHaflCHHa JIHUCBOH BCHbl - HpH CCHCHCe).
B»3Ka Hapy>KHOH COHHOH apXCpHH, XOH3HJIJI3KXOMHa. ECJIH UieHHaX (})JierMOHa OC-
JlexanbHocxb npn asHHbix ocno>KHeHHax Bbicona, oGycjioBJiena oSmHM xa^cejibiM
cocxoaHHCM 6onbHoro.
Ilapamotaujuium aBJiaexca CJICACXBHCM pacnpocxpaneHHa ocxporo BocnanHxejibHoro npouecca c He6nbix MHHflajiHH na napaxoH3HiuiapHyio KjiexnaxKy H xapaKxepnsyexca ee BocnanHxejibHOH HH(J)HJibxpauHeH (oflno- HJIH flByxcxopoHHCH).
TlapamonjujijiHpiibiii a6cu,ecc aBJiaexca Han6onee nacxbiM ocuoacHeHHCM
ocxporo HJIH o6ocxpeHHa xpoHHnecKoro xoHSHJUinxa.
PasjiHiaiox oxeHHyio, HH(J)HJibxpaTHBHyio (napaxoHSHJiuiHx) H a6cue/jHpyiomyro cxa^HH BocnajinxejibHoro npoueccs B OKOJiOMHHjiajiHKOBOH KJiexnaTKe.
BojibHbie 5Kajiyioxca na GOJIH B ropjie, HppaflHHpyiomHe B yxo, xpH3M. IlpH MCSO-
jiomwexca cencncoM, MCflHacxHHHXOM, Heo6xoflHMO BCKpbrrne OKOJiornoxoHHoro
npocxp3HcxB3 aonojinaxb KOJinapHOH Me^HscxeHOxoMHeH.
SazjiomoHHbiu adcqecc. FHOHHOC BOcnajiCHHe KJiexnaxKH H jiHM<J)axHHecKHx
y3HOB 3araoxoMHoro npocxpancxBa Bcxpenaexca npeHMymecxseHHO B paHHeM
aexcKOM Bospacxe. Hnoraa 3arjioxoiHbiH a6cuecc Bcxpenaexca y Bspocjibix nocjie
XpaBMbI SaflHCH CXCHKH FJIOXKH HHOpO^HblM XCJIOM. J\M yCXaHOBJICHHa ^H3FHO3a
HeoGxoflHMbi 4>apHHrocKonHa, najibueeoe HCCJie^OBaHHe TJIOXKH H penxreHorpa4>na men. Y GojibHwx oxMenaexca BbmyHweHHoe nojioaceHHe rojiOBbi (naKJiOH
H B cxopony), HapymeHHC rjioxaHHa, 6ojib B ropjie, uiyMHoe, xpnnaiiiee
C, noBbimeHHe xeMnepaxypbi, yBCJiHHeHHe H GojiesneHHOcxb pernoHap-
Teivia VIII. SAEOJlEBAHUfl ITIOTKH.
150
HHX uieHHbix JiHMcJjaTHiecKHx ysjiOB, rnycaBbiH ronoc. fliw sarjioxonHoro a6cnecca xapaKxepeo ocxpoe, pe>Ke nocxeneHHoe Hanaro, cBasaHHoe c H
(OPS, ocxpbiH aflCHOHflHT, flexcKHe HH(j)eKUHOHHbie sa6ojieBaHHa, ocxpbifi
HHH OTHT). BOJICIOT, KaK npaBHJio, JJCXH 40 3-x JICT, cxpaflaromne paxnxoM, rnnoXpO^HCH, paCCTpOHCTBaMH ITHXaHHH.
IlpH 4>apHHrocKOHHH onpe/jejiacxca 6arpoBO-KpacHoe BbinawHBaHHe sa^neS
CXCHKH FJIOTKH Cnp3B3 HJIH CHCB3 OT Cpe/JHeH JIHHHH, HHOrfla C o6eHX CTOpOH npH
omynbiBaHHH najibucM HJIH uinaxejicM onpe,aejiaexca (JwiioKxyauHa, ne6Hbie Jjy>KKH H MHHflajIHHbl HHTaKTHbl.
IlpH jioKanHsauHH a6cuecca B HOCOPJIOXKC HMeexca pesKoe napymeHHe HOCOBoro jjbixaHHfl, saicpbixaa raycaBocxb, o6mibHoe BbiaejieHHe CJIHSH HS Hoca, npn
(J)apHHrocKonHH onpe/jejiaexca CMemeHHC MarKoro He6a Knepean, (jwiioKxyHpyiomHH HH(j)HJibxpax sa^HCM CXCHKH TJIOXKH BH^CH, ecjiH MarKoe ne6o npnnozinaxb uinaxejieM.
ITpH jioKajiH3ai;HH aGcuecca B ropxanorjioxKe flbixanne pesKO saxpyflHeno,
xpnnamee, npeHMymecxBCHHO saxpyflHCH BJJOX, rjioxanHe HCBOSMOSKHO, rojioaa
sanpoKHHyxa Hasaa, BO pxy H poxoraoxKe Gojibmoe KonHiecxBO CJHOHW, 4>JiiOKxyHpyromHH HH(})HJibxpaT 3a^HeH CXCHKH ropxaHorjioxKH onpejjenaexca, CCJIH
uinaxejieM oxxanyxb KopeHb asbnca Knepe^H HJIH omynaxb 3aflHioK) cxeHKy ropxanorjioxKH najibijeM.
flHarno3 sarjioxonnoro aScuecca cjiejjyex nposoanxb c
XCJIOM ropxaHorjioxKH H xy6epKyjie3HbiM cnoHJjHjiHXOM uieHHbix no3BOHKOB. Heo6xoflHM no/ipo6HbiH anaMHes, peHxreHorpa(J)Ha UICH.
Jlevenue xnpyprHHecKoe, na (J)OHe npoxHBOBOcnajiHxeJibHOH H HH(J>y3HOHHOH
xepanHH npoBOflnxca BCKpbixne a6cuccca. Ilpn a6cuecce, BbinaHMBaromeM sajjHK>K> cxeHKy poxorjioxKH, rHOHHHK BCKptiBaiox Hepes nojiocxb pxa. Ilepefl BMCuiaxejibcxBOM flJia npe^ynpoimeHHa moKa H pe<})JieKxopHOH ocxanoBKH flbixanna
BHyxpHMbimeHHO 50 % pacxBop aHajibrHHa H 0,1 % pacxBop axponHHa B
, cooxBexcxByiomnx Bospacxy 6ojibHOro. C uejibio npo(J)HJiaKXHKH acnnpaIIHH rnoa ncpcfl BCKpbixHCM a6cuecca npoBo^ax ero nyHKunio H acnnpaijHio
rHOHHoro oxflejiaeMoro. Bojibnoro (J)HKCHpyiox KaK nepea y/iajieHHCM
ro xejia H3 Hoca, uinaxejieM yaep^HBaiox astiK, ocxpOKOHennbiM
jiesBHe Koxoporo cjieflycx o6epnyxb jieHKOiuiacxbipeM Ha paccxoaHHH 0,5 CM ox
KOHua, npOHSBOflax npOKOJi H BepXHKanbHbiH paspes a6cqecca csepxy BHHS B
Mecre HaH6ojibiuero BwnaHHBaHHa; jiHHHa paspesa aoJiacHa oxcxoaxb ox cpe/jHeft
JIHHHH FJIOXKH HC 6ojiee ICM na 1,5 CM. THOH HS paspesa, MOMenxajibHO sanojiHaioiuHH poxoraoxKy, y^ajiaiox 3JieKxpooxcocoM, HaioiOHHB GojibHoro FOJIOBOH
BHH3. 3axeM KOpHqanroM no^ KOHXPOJICM jioGnoro pe4)JieKxopa OKOHHaxeJIbHO
onopoacHarox nojiocxb aScuecca H CHOBa acnnpHpyiox THOH. Ha CJieflyroiHHH fleHb
nocjie onepauHH pasBeaenHe Kpaes paspesa H yjjajieHHe rHoa noBxopaiox. Upu
a6cuecce, BbinaqHBaiomeM saj^Hioio cxeHKy HOCOFJIOXKH, ncnojibsya poxopaciiiHMareoe ne6o uinaxejieM, paspes CXCHKH a6cuecca npOH3-
TOH3MnnorEHHblE OCnO>KHEHHfl
151
BO/xax CHH3y BBepx. ripn a6cuecce, BbinaHHBaiomeM sa^HioK) cxeHKy ropxanorJIOXKH, paspes raoHHHKa npoHsaoaax csepxy BHHS no yKasaxejibHOMy najibuy JieBOH pyKH, BBe/jenHOMy nepes pox B ropxanorjioxKy, na sa^neS cxenKe Koxopofi
najibonpyexca Mareaa, (})jnoKxyHpyiomaa onyxoJib.
ToH3UJinozeHHbiu MeduacmuHum o6biHHO BOSHHKaex KaK pesyjibxax yace
paccMOxpeHHbix OCJITOKHCHHH BcneacxBHe pacnpocxpaneHHa rHOHHoro npouecca
no KJiexnaxKe, pacnojio)KeHHOH no xo,ay cocy^Hcxo-HepBHoro nynKa IIICH, Ha
KjiexnaxKy cpejjocxeHna. OxMenaioxca GojiesneHHaa npHnyxjiocxb H nacxosnocxb
6oKOBOH noBepxHOCTH men.
ToH3UJinozeHHbiu cencuc — caMoe xancejioe HS OCJIOJKHCHHH ocxpux XOHSHJIJIHXOB. HCTOHHHKOM oGuiCH THOHHOH HH(})eKUHH HaiUC BC6FO aBJiaeXCa OCX-
PWH .HJIH xpOHHHecKHH xoHSHjijiHX, napaxoHSHJUiapHbiH, napa(J)apHHreajibHbiH
aScqecc, raoHHbiH JiHM^a^eHHX, BOSHHKaiomHH B csasn c ocxpbiM BocnajiHxejibHHM npoqeccoM B rjioxKe. B saBHCMMOcxn ox cnocoSa pacnpocxpaneHHa HH(J)eKIIHH HS MHHjjajiHH B KpOBaHoe pycjio pasjiHHaiox cjieAyiomne (J)opMbi XOHSHJUIOreHHoro cencHca:
1) reMaxoreHHyio, o6ycJioBJieHHyio npoHHKHOBCHHeM B BenosHyio cncxeMy
XOKCHHOB H 6aKxepHH Hcpes cocyflbi MHH/jajiHKOBoro jioaca;
2) xpoM6o(J)jie6HXH4ecKyK> — KaK pesyjibxax cenxHHCCKoro xpOM6osa KpynHWX BCH iiieH c o6pasoBaHHeM rHOHHbix MexacxasoB BO BnyxpeHHHx opranax;
3) JiHM<j)oreHHyK) (jiHM4)OHOflyjiapHyio), CBflsaHHyro c HarHoeHneM rjiy6oKHx
perHOHapHbix uieHHbix jiHMcJjaxHHecKHX ysjiOB na pasBHjiKe o6meH JIHUCBOH H
apCMHOH B6H C npOpblBOM THOa B BCHOSHOC pyCJIO;
4) (Jjjiei'MOHosHyio, Kor^a nopaaceHHe KpynHbix BCH men oSycjioBJieno <J)JierMOHOH napa<J)apHHreajibHoro npocxpancxBa.
FeHepajiHsaaHH xoHSHjuioreHHOH HH(J>eKUHH cnoco6cxByiox pasjiHHHbie (JiaKxopw, Be/rymHe K cpway HMMynopeaKXHEHOcxH (flna6ex, rpnnn, JieneHHe KopxnxoHSHJijioreHHoro cencHca xapaKxepen pesKHH noateM xeMnepaxypw
xejia (AO 40 °C H Bwine) nocxoaHHoro xapaKxepa HJIH c 6ojibiiiHMH pasMaxaMH H
noxpacaramHMH osHo6aMH. O6mee cocxoaHne onenb xa»ejioe: nyjibc MarKHH H
nacxbifi; asbiK o6jio>KeHHbiH, cyxon; seMJiHcxbifi c cy6HKxepH4HWM OXXCHKOM
UBex JiHua; HenpHaxHbiH sanax HSO pxa; yBejinneHHe neneHH H cejieseHKH. B sese
o6Hapy»CHBaioxca npHsnaxH ocxporo HJIH o6ocxpeHHa xpoHHnecKoro XOHSHJIJIHxa, Hepe/;KO y)Ke HCHesaioujHe, HJIH CHMOTOMW napaxoHSHJUiapHoro a6cLtecca.
KaK npaBHJio, oxMe^aioxca HSMeneHHa B o6jiacxH cocyflHCXoro ny^Ka men.
OSbiHHO o6napy»cHBaexca GojiesHCHHOcxb npH rjiyGoKoii najibnauHH apeMHoB
BCHW, ocoGeHHO ee BepxHero oxflejia nosa/jH yrjia HHHCHCH nejiiocxH. Opn xpoM6o<}>Jie6HXHHecKOH 4>opM6 cencHca onpe^ejiaexca BojiesHeHHbiH ism. B/jojib nepeflHero Kpaa KHBaxejibHOH Mbimu,bi. Ilpn jiHMiJioreHHOH (J>opMe npomynbisaioxca
imoxHbie 6onesHCHHbie naKexu ray6oKHx H nosepxHOCXHbix meHHbix, noanejiK)CXHWX, nOa6opOaO4HbIX JIHM(})aXHHeCKHX ySJIOB. IIpH (J)JierMOH03HOH (JlOpMC H3
152
Teiwa VIII. SABOJIEBAHMfl TJIOTKH.
mee B o6jiacxn yraa HHHCHCH HBJIIOCXH najibnnpyexca IUIOXKHH, 6ojie3HeHHbiH
HH(J>Hjibxpax, sanojiHaiomHH sanejifocxHyK) HMKy H HHorfla pacnpocxpaiMioinHHca BHHS flo KJiK>HHUbi; o6napy>KHBaioxcH xaioKe .apyrne npH3HaKH napa(J)apHHreanbHoft (f>jierMOHbi. XapaKxepno o6pa3OBaHHe MexacxasoB FHOHHOM HH^CKUHH,
Koxopue HanGojiee nacxo jioKanroyioxca B JiencHx, oflHaico Moryx Ha6jnoflaxbca H B
noHKax, cepflue, MO3re, cycxasax H flpyrax opranax. ,E(jia xpOM6o(J)Jie6HXHHecKOH
(j)opMbi xoH3HJinoreHHoro cencHca xapaicxepHO perporpaanoe pacnpocxpaneHHe
HH<{>eKUHH no BCHOSHOMy pycny. TpOM6o(J)jie6HXHHCCKHH npouecc H3 xpeMHOH BCHbi MO5KCX pacnpocxpaHHXbOi nepes ee nyKOBHuy B cnrMOBH^HbiH H nonepeHHbiH
MosroBwe CHHycw. BOSMTOKBH xpOM6o3 KaBepnosHOro CHHyca BCJiejjcxBHe pacnpoClpaHCHHfl HH(J)eKUHH OO BCHaM FHOXOHHOrO, KpbLHOHe6HOrO CnJlCXCHHa H OpSHXbl.
Kax ocjiojKHCHHe xpoMGosa MOSFOBUX CHHycos MOHCCX passHXbca MCHHHrHX, a6cuecc Mosra. Ilpn MOJIHHCHOCHOM cxa<})HiioKOKKOBOM cencnce Ha6nK)flaK)xca npn3H3KH ocxpOH cep^eHHOH (npeHMymecxBCHHO neBOMcenynoHKOBOH) He^ocxaxoHHOCXH H cxpax CMepxH. IlpH cencHce, Bbi3biBaeMOM rpaM-oxpHiiaxejibHOH (JmopOH,
MOJKCX pasBHXbca 6aKxepHanbHbiH IIIOK: Ha6jiK>flaexca MpaMOpHocxb KO>KH, KOHjianxoHflHbie naxna, nyjibc cxanoBHTca HHxeBH^HbiM, Kaxacxpoc})HHecKH naflaex apxepHajibHoe flaBJieHne. Mop4>ojiorHHecKaa KapxHHa GCJIOH KpoBH xapaKxepnsyexcH
HeHXpO(J)HJlbHbIM JieHKOU,HTO3OM CO CflBHFOM BJ1CBO, JICHKOneHHa H aH3O3HHO(j>HJIH5I
HBnaroxca nporHocxHHecKH HeGnaronpnaxHtiM npHSHaKOM. Co cxopoHbi KpacHOH
KpoBH oxMenaioTca 6bicxpo Hapacxaromaa aneMHa c nafleHHCM HHCua apHxpouHXOB
H yMCHbiueHHeM coflepacamM reMoraoSHHa, noasjieHHe noHKHjioqHxosa H aHH3oUHXosa, SHaMHxejibHO yBenHHeHHaa CO3. B MOHC o6napy»cHBaK)xca 6enoK H raaJIHHOBblC UHJlHHflpbl, HHOFfla 3pHXpOl(HXbI, JieHKOU.HXbI.
/],HarHO3 xoH3KJiJioreHHoro cencnca ycxanaBJiMBaexca na ocHOBaHHH KJIHHHH6CKOH KapXHHbl H HajlHHHfl OHara HH^eKUHH B FJIOXKC. Heo6xOflHMO HCKJIIOHHXb
flpyrHe HCXOHHHKH cenxHHecKoro npouecca. PaHHHM npHSHaKOM reHepajiHsaqHH
XOHSHJLHOreHHOH HH(|)eKUHH MO^CCX HBHTbCH HCOflHOKpaXHO nOBXOpHK>mHHCfl HUH
nOSflHO B03HHKaK)mHH CHJIbHblH O3HO6 C o6HJlbHbIM nOTOOXflCJICHHeM H3 ^OHG
saxHxaiomHX HBJICHHH aHFHHbi.
Jlfta noflXBepacflCHHa flHaraosa xoH3HiuioreHHoro cencnca npoHSBO^ax 6aKxepHonorHHecKoe HCCJieflosaHHe KPOBH. OnxHManbHbiM BpeMeHCM fljia noceBa
KPOBH aBJiaexca HanajibHbiH nepnofl 03Ho6a.
Jlenenue saKuroHaerca B cponnoM xHpyprHHCCKOM BMeiuaxejibcxBe na 4>OHe
npoxHBOBOcnajiHxeJibHOH, HH4)y3HOHHOH H HMMyHOxepanHH. Ilpn reMaxoreHHoft
4>opMe cencHca npoH3BOflax XOHSHJUISKXOMHIO. Ilpn (j)jierMOHO3HOH <J)opMe B nepByio onepeflb noKasano uinpOKoe BCKpbixHe napa^apHHreajibHOH 4>JierMOHH, a 3aXCM XOH3HJlJI3KXOMHa. ECJIH HMCCXCa nOflOSpCHHC Ha XpOM6o(J>Jie6HXHHeCKyiO HJIH
JiHM(|)OHOflyjMpHyio 4>opMy, nponsBOflHxca uiCHnaa MCflHacxHnoxoMHa c nepeBasKOH H HcceneHHeM xpOMGnpOBanHbix ynacTKOB BBH, yflajienHc nopa>KeHHbix JIHM4>axHHecKHX ysjioB H flpeHHpoBaHHe napaxoH3HJinapHoro H napa<})apHHreajibHoro
npocxpancxBa. IlpH xpoM6o4)Jie6HXHHecKOH 4>opMe oGecnenHBaerca
153
TOHSH^norEHHblE
xepanna aHXHKoaryjiaHxaMH. /Jjia BbiBCflCHHa 6onbHoro HS 6aKxepHajibHoro moKa
BHyrpHBCHHO BBOflax npeflHHSOJiOH (300-700 Mr), renapnH (30 000-60 000 EJJ, B
CyiKH) H H30XOHHHCCKHe rJIK)K03O3JieKXpOJIHXHbie paCXBOpbl flO 3-7
JI B CyXKH.
Bonpocbi Ann vnoroBoro KOHorponn 3H3HMM no rewe VIII
1. MeM OT^MMaiOXCfl nepBMHHbie XOH3HriJ1MTbl OT BTOpMHHblX?
2. C K3KMM MHKpoopraHM3MOM HanSonee nacxo CBnabieaiOT STUOJIOrmo aHrnH?
3. KaKOBbi o6teKTMBHbie ox/iMMHTenbHbie npusHaKM KaxapanbHoPi ani n ociporo cpapMHrma?
4. HasoBuxe cpopMbi nepBMHHort anrHHbi B aasncuMOCTH ox MopcponoM3MeH6HMM MMHflanMH.
5. Kaiwe MHTn6aKxepnajibHbie cpeflcrsa CHuraKDicfi npenaparaMM
BblGopa flflfl JieM6HM51 aHPHH?
6. KaKne npn3HaKM flMdpxepuM or/iMMaiox ee or flpymx BocnannxenbHblX 3a6oJ16BaHHM mOXKM?
7. flpn KaKnx cnequcpunecKnx 3a6o/ieBaHMflx BOSMOKHW Bocna/imenbHbie V\3M6HeHV\f\ MMHfla^MHaX?
8. KaK npopB/iflKJTca wecxHbie ocno>KHeHM5i TOHSM/IJIMTOB?
9. nepeMMcnme oco6eHHOCTM icnuHMMecKOM KapiMHbi aarnoroHHoro
a6cqecca.
10. Ox KaKoro ocno>KHeHMn MOKBX norn6Hyxb 6onbHovi c 3amoTOHHbiM
a6cqeccoM?
11. nepeHncnme cpopMbi xoH3minoreHHoro cencuca.
OTOrEHHblE BHYTPHMEPEnHblE OCJlO>KHEHHfl
eMa IX.
3AEOJ1EBAHMH YXA. OTOPEHMblE
BHYTPMHEPEnHblE OCJlO>KHEHMfl
Bpeun aaHflTMn — 180 MMHyr.
L|ejib aaHjjTMH. HayMMTb K/iMHMKy, A^amocTHKy M
npMHLinnbi neMeHMM socnanMTenbHbix 3a6oneBaHHM yxa
M OToreHHbix BHyrpunepenHbix ocno>KHeHMM.
1. Pasogparb KJiMHHHecKMe oco6eHHOc™ Hapy>KHbix
OTMTOB.
2. Pa3o6patb KJIHHMKY, fluamocTHKy, JieseHne OCTporo M xpoHMMecKoro moMHoro cpeflHero orma.
3. OSHaKOMMTbCfl C COBpeM6HHblMM CpapMaLjeBTMHeCKMMM npenaparawid Ana ne^emw BocnanmejibHbix sa6oneBaHMii yxa.
4. PaaoOpaTb noKaaaHMH, rexHMKy McnonHeHun oneparnBHbix BMeLuarenbCTB Ha yxe.
5. Pa3o6paib ocHOBHbie cnHflpOMbi ororeHHbix BH/TpuMepenHbix
6. PaaoSparb oco6eHHocTM reseHUp cpeflHMX OTMTOB B fleTCKOM soapacTe.
OcHameHne. OcBeTMTeribHbie npn6opbi: MCTOMHMK
CB6T3, Jlo6HblM peCfineKTOp. fleMOHCTpaL(MOHHblii M3T6pnan: nnaKaTbi, cnaiiAbi.
Ha6op MHCTpyueHTOB. HocoBbie aepKana, mnaTeJIM, HocornoTOHHbie aepKana-, aoHflbi HaeMBHbie, riMHqeTbi
HOCOBbie.
PaBonee uecro. HHCTpyMeHTa/ibHbiM CTOJIMK, nanaivina, cnnpTOBKa, ABB CTyna.
Mecro nposefleHun sansiTMH. VneGHaK KOMHara.
1. Co/idamoe \A. B. JleKqun no OTopyHO/iapMHronoTHM. — M.: MeflMMMHa, 1990.
2. LUeepbiauH B. B. PyKOBOflCTBO no fleTCKOM /
HO/iapuHronornM. — M.: MeAMUMHa, 1985.
155
B crpyKxype oxopHHonapHHrojiorHHecKOH 3a6oJieBaeMOCTH SO^CSHH yxa
CTOST na xpexbeM Mecxe nocjie SonesHen noca H ero npHAaxoHHbix nasyx H rjioxKH. PacnpOCTpaHCHHOCTb, a xaiOKC Me^HKO-3KOHOMHHeCKOe H COUHaJlbHOe 3H3HeHHC naxonorHH yxa bnpeaenaiox aKxyajitHocxb naxonorHH yxa, xyroyxocxH B paay coBpeMCHHbix npo6neM oxopHHOJiapHHronorHH.
BocnajiHreJibHbie saGojieBanHH Hapy/KHOro yxa no npHHHHe BOSHHKHOBCHHH paszienarox Ha:
I. TpaBMaxHHecKHe HapyacHbie OTHTH:
— oxoreMaxoMa;
paKOBHHbi, HapyacHoro cnyxoBoro npoxo^a;
KO3KH yiiiHOH paKOBHHbi, Hapy>KHoro
cnyxoBoro npoxo/ja.
II. AnjieprHHecKHe napy^KHbie OXHXH.
III. HH(J>eKU,HOHHbie napy»(Hbie OXHTM:
— BHpyCHHH HapyHCHblH OTHX;
HbiH HapyxcHbiii OXHX;
Hapy>KHbifi OXHX;
OTHX CMeiuaHHoro reHesa.
IV. HapyaCHblH OTHT BCJICflCXBHe BOSflCHCXBHH (J)H3HHeCKHX (})aKTOpOB (O5KOTH, OTMOpWKCHHfl).
OroreiviaTOMa — cKonneHHe KpOBH Me>K£y HaflxpaiuHHqeH H xpamoM yiiiHOH
paKOBHHbi. MexamoM xpaBMbi — yaap xyxibiM npe^McxoM HUH caasjieHHe yiiiHOH
paKOBHHbi no KacaxenbHOH, Kor^a cos^aioxca ycjioBHs JUM CMemeHHa CJIOCB: KOJKH
H HaflxpamHHHbi, HaflxpHujHHUbl H xpama. IIpH OXCJIOHKC HaflxpamHHUbi ox xpama
npOHCxoflHx paspbiB cocyaoa, H na onpeaejieHHOM yqacxKe Me»yxy HHMH CKaruiHsaexca KpoBb. OxoreMaxoMa irpe/icxaBJiaex coSoii (JmiOKxyHpyiomyio, nanpaaceHnyio npHnyxjiocxb B BepxneH HUH cpe^Hen xpexn yuiHoii paKOBHHbi. I^BCT KOXCH B
MCCXC OTOrCMaXOMbl MO5KCX 6bIXb He HSMCHCHKblM HJ1H SarpOBO-CHHIOIIIHHM, CCJIH
B 3TOM 5KC MCCXC HMCBXCa nO^KOXCHOe KpOBOH3JIHaHHe.
Jleienue. PeKOMeHflyerca coaep»HMoe oxoreMaxoMH acnnpHposaxb mnpHUBM H saxeM nanoacHTb AaBamyio nosasicy. Ilpn sHaiHxejibHOM pasMepe oxoreMaxoMbi 3xy npoueaypy noaxoparox HecKOJibKo pas. IlauHeHTaM peKOMeHflyexca
npHHHMaxt npenapaxbi, cnocoGcxByiomHe noBbiineHHio CBepxwBaeMocxH KpoBH
(aCKOpyTHH, 4HUHHOH, KaJIblJHa PJIIOKOHax), 3HTH6HOXHKH KypCOM 5-7 aHCH.
IIpH He3(j)4)eKTHBHOCXH JieHCHHa, paSBHXHH XOH^pOnepHXOH^pHTa yiUHOH paKOBHHbi npHMCHaerca xHpyprHnecKHe JieneHHe.
XonaponepMxoH/ipm YIIIHOH paKOBHHbi nepeflKO passHBaexca KaK cne^cxBHC oxoreMaxoMH, HO MO5KCX BO3HHKHyTb npH pacnpocipaHCHHH BocnajiHxcjibHoro npouecca c KOMCH yiiiHOH paKOBHHbi HJIH npn yKyce naceKOMoro.
BHCUIHHH Bna yuiHOH paKOBHHbi 6bicxpo HSMenaexca xapaKxepHbiM o6pa30M: KO5K3 BCpXHCH H CpeflHeH XpCTH yiiiHOH paKOBHHbi, KOXOpOH HOflJIOKHX
, rHiiepeMMpoBana, oxeina, a KO>Ka MOHKH yuiHoii paKOBHHbi HC
156
TeMa IX. 3A5OJ1EBAHH?) YXA.
YiacxoK BOcnajieHHoro xpaiua H HaflxpaiuHHUbi pesKO OXCHCH, HXO
craaacHBaex pejibe(|) H yxonmaex ymnyio paKOBHHy B Mecxe socnajieHHa. Hacxo B
30HC xoHjjponepHxoHJjpHxa npOHCxo^Hx rnoHHoe paciuiaBJieHHe xpama c oxxopMCCHHCM HCKpoxH3HpoBaHHbix xKaHCH. HpH He6jiaronpHaxHOM xeneHHH
nepnxoH/ipHX Moacex pacnpocxpaHHXbca c yniHOH paKOBHHbl na xpamesoH
napyacHoro cjiyxosoro npoxojja. Hcxofl xoH^ponepHXOHjipHxa — cxoBKaa ae4>opM3HHa yujHOH paKOBHHbl, ee yxojimeHHe H rpy6oe HSMeneHHe pejibetfm. Ho4o6Hbie yuiHbie paKOBHHbl nepe/iKO MTOKHO yBH^exb y cnopxcMeHOB-6opuoB, B
caasH c HCM xapaKxepHo HSMeneHHyio yiiiHyio paKOBMHy H33biBaiox «yxoM SopHaw. /Jec|)opMauHa napy>KHoro cjiyxosoro npoxoaa npH xoH/jponepHXOHapHxe
Moacex npHBecxH K ero CXOHKOH axpesHH.
/],H(j)4)epeHHHpOBaxb xoimponepHXOHApHX cjie,zryex c KOWHHMH 3a6ojiesaHHaMH — po>KHCxbiM BOcnajiCHHCM H £pyrHMH HH<J>eKUHOHHbiMH H ajuieprHHeCKHMH AepinaxHxaMH, co sjioKanecxBeaHbiMH onyxonaMH yuiHOH paKOBHHbl. OxjiHHHxejibHbiMH npHsnaKaMH KoacHbix 3a6ojieBaHHii aBJiaioxca: BOBJieneHHe B
npouecc MOTOH, pacnpocxpaneHHe KOJKHWX H3MCHeHHH sa npeaenbi yuiHOH paKOBHHbi. HpH onyxojieBOM npouecce oxjinnaexca anaMHes 3a6oJieBaHHfl; fle<j)opM3HH3 yUIHOH paKOBHHbl COHpa>KeHa C KOaCHblMH H3MCHeHHaMH.
Jlenenue. flflu yaajiCHHa HeKpoxH3HpOBaHHbix H H3MCHeHHbix ynacxKOB xpama Bbinojinaexca onepauna — OKonnaxaa peseKUina yiiiHOH paKOBHHbl. flpcTyn K
HSMCHCHHOMy xpaujy ocymecxsjiaiox nepes xbuibHyio nosepxHocxb yuiHOH paKOBHHbl, npOBOZW pa3pC3 K05KH H Ha^XpamKHIIbl HapSJIJiejlbHO CB06oflHOMy Kp3K)
yuiHOH paKOBHHbl na BceM npoxajKCHHH saneraiomero BHyrpn xpams. Ha I axane
onepau,HH Koacy c HaaxpamnHijeH Heo6xoaHMO OTcenapOBaib uinpoKO H o6Haxpam ymHoii paKOBHHbl ^o HeHSMenenHbix XKaneH. HeKpoxnsHpOBaHHbie
yaanaioxca nojiHocxbK). 3axeM B xpauje yuiHOH paKOBHHbl Btipesarox «OKHO», Koxopoe saxBaxbiBaex B ce6a see HSMenenHbie XKaHH. Hepe^Ko B sony oKHa
npaKXHHCCKH Bccb xpam yuiHOH paKOBHHbl. Ilocjie 3xoro oxcenapoBaHJiocKyx KO>KH H HaflxpaiiiHHUbi yKJiaabiBaexca na MBCXO H pana yuiHsaexca.
II axanoM onepauHH npoBOflax (jjopMHpOBaHne penbe<J)a yuiHoii paKOBHHbl.
3xoro (JjopMHpyrox cKJia^KH saBHXKa H npoxHBOsaBHXKa H 4>HKCHpyiox HX
MapJiesbiMH BanHKaMH, CKBOSHMMH, nepes yuiHyio paKOBHHy, iiiBaMH. Ha yuiHyio
paKOBHHy HaKJiaflbiBaEOx acenxHnecKyK) nosasKy. B nocjieonepauHOHHOM nepnofle 6ojibHbiM Ha3HanaK>x aHXHSnoxHKH. IllBbi c sayiiiHOH panbi CHHMaiox Ha 7—
1 O-H flCHb, 4)HKCHpyiomHe BajiHKH — Hepcs 2 HeaejiH.
ABcijecc MOHKH VIIIHOH paKOBHHti asnaexca ocjioacneHHeM npOKOJia MOHKH. HoCKOJIbKy flJia (JlOpMHpOBaHHa CXOHKOFO CKB03HOFO OXBCpCXHa MOHKH HOCJie
MaHHOyjiailHH HeoSxOJIHMO Co6jIH3fleHHe acenXHICCKHX yCJIOBHH, BHKOXb
nonHoro saacHBneHHa paHbi, a ^exn H noapocxKH nepe^KO Hapyiuarox ^aHHoe
eflnncaHHe, aScuecc MOHKH yxa HaH6onee qacxo Bcxpenaexca B ^CXCKOH npaKe. KjiHHHKa 3a6oneBaHHa xnnHHHa: Ko»ca MOHKH yxa ranepeMHpoBaHa, oxenna, na HCH HMeexca Konoxaa p3H3, MOHKa yx3 (JwiioKxyHpyex.
157
OTOrEHHblE BHYTPHHEPEnHblE OCnO>KHEHH3
JJenenue. AGcqecc MOMKH Heo6xoflHMo BCKpbixt, nonocxb a6ciiecca o6pa6oxaxb 3 % nepeKHCbK) Bo^opofla. J\o nonnoro oinmeHHa HOJIOCXH npoBo^ax ee
^peHHpoBaHHe nepnaxoHHOH pesHHoii H MapjieBWMH BbinycKHHK3MH c ranepxoHHHCCKHMH paCXBOp3MH. BOJIbHbIM Ha3H3H3K>X 3HXH6HOXHKH KypCOM 5-7
flH6H.
Hii(|)HUiipODaiiiibie noBCpxiiocrHtie pesaHbie, paaHbie, yinn6.TeHHbie noBpe>K4eiiHn KOiKH VIIIHOH paKOBHHbl if Hapyxciforo cnyxoBoro npoxoaa nenar
K3K HapyHCHblH HH(J)eKHHOHHbIH OXHX.
AJiJieprHHCCKHe (aronHHCCKHe) HapyjKHbie OTHTW — npoaBJienHe 3K3eMW, pacnpocTpanaiomeHca c COCC^HHX o6;iacxeH Ha K0»cy yuiHoii paKOBHHbl H
HapyacHoro CJIyxoBoro npoxo^a. BonbHoro 6ecnoKoax "syn, 6onb B yxe. MoKHymaa noBepxnocxb Sbicxpo HH^nunpyexca H HaraaHBaexca.
Jlevenue. TIpOBOjyn JieneHHe SKseMbi. 3HaaypanbHO Ha3H3Haiox KamiH H M33H,. co^ep>KaiHHe aHXHSnoxHKH H cxepOH^Hbie ropMOHbi.
Hii(J)eKunoiinbie napy^KHbie OTHTBI no pacnpocxpaHCHHocxH aenax na orpaHHHeHHbie H AH(f>4)y3Hbie. K orpaHHMeHHbiM 4>opMaM oxnocax ocxHO(})OJiJiHKyHHX H (JiypyHKyji KOSCH. Hpn ^H(})(J)y3HOM nopa>KeHHH B BOcnajinxeJibHWH npouecc, K3K npsBHJio, BOBJieneHa Bca Ko»ca HapyacHoro cnyxoBoro npoxofl3.
BHpycHbiii iiapy/KHbiii OTHT (cHH/ipOM Xsnxa) — yuinaa 4>opMa onoacbiBaioiuero uniiiaa. BosSy^nxenb — snpyc repneca II xnna. BoJibHwe acajiyioxca na
6ojib B yxe. Hnoraa BO3HHKaex acHMMexpna jiHua sa CHCX conyxcxByiomero nopaaceHHa nnqeBoro Hepsa. HpH OXOCKOHHH Koaca Hapyacnoro cnyxoBoro npoxoaa
FHnepeMHpoBaHa, na cxenKax cnyxoBoro npoxo/ta, na 6apa6aHHOH nepenoHKe
MOXCHO yBHjjexb MHoacecxBCHHbie, HC cJiHsaiomHeca nysbipbKH. B flanbHeHiueM
nyswpbKH ^onaroxca c oSpasoBaHHCM KOponeK.
Jlenenue npOBO^nxca B ycnoBHax HeBponorHHecKoro oxfleneHHa cxaunonapa
c npHMeHCHHCM /^HKasbi, AesHHTOKCHKaqHOHHbix cpeACXB,. BHxaMHHOB rpynnbi
B, nposepHHa, anajibrexHKOB. SnaaypanbHO nasHanaiox npoxHBorepnexHMecKHe
M03H. Hcxoa, K3K npaBHJio, 6jiaronpHaxHbiH.
OypyHKy^ napyacHoro yxa. JIoKaJiHsauna (J)ypyHKyna BOSMoacna xojibKO B
xpameBOH nacxH Hapy*Horo CJIyxoBoro npoxo^a HJIH Ha KOHCC yuiHOH paKOBHHbl.
B KOCXHOH nacxH napyxcHoro cjiyxosoro npoxo/ja (J>ypyHKyjibi ne oGpasyroxca,
X3K K3K BOJiocbi B Hen oxcyxcxByiox. HpH (jjypyHKyjie Hapy»cHoro cjiyxosoro
npoxoaa 6ojibHbie 5Kanyioxca na 6ojib B yxe nyjibcnpyiomero xspaKxepa. Bojib
ycHJiHBaexca B Benepnee H HOHHOC BpeMa. ECJIH (JjypyHKy^ JioKaJinsyexca na nepeflHefl HJIH HH5KHCH CX6HKC CJiyXOBOFO HpOXOfla, yCHJICHHC 6OJ1H HpOHCXOJJHX
npn jjBHMceHHax BHCOHHO-HHxcHeHejiiocxHoro cycxasa BO spemn pasroeopa,
npncMa nnmn H x. a. Cnyx He cxpa^aex. YxyauieHHe cjiyxa MOHCCX conyxcxBosaxb SojibinoMy cjjypyHKyjiy, Ror^a oGxypnpOBaH npocsex CJIyxoBoro npoxoaa.
HpHHaHnw JieneHHa (J)ypyHKyjia Hapy>KHoro yxa cooxBexcxsyiox jieneHHio 4>ypyHKyjia Hoca, onncaHHOMy B paa^ejie «3a6ojieB3HHa Hoca».
Hapy/KHblii iIH(|)(J)V3HblH HH(])eKUHOHHblii OTHT
OCXpOC HJIH XpOHHHe-
CKOC HH(J)eKUHOHHoe BOcnajiHxeJibHoe saSojiesaHHe KOHCH napyacnoro CJIyxoBoro
158
Tewa IX. SAEOJlEBAHMfl YXA.
npoxc«a. IlpejipacnojiaraiomHMH 4>aKxopaMH cHHxaroxca nepeoxjiaayieHHe, CHH>K6HHe MecxHoro HMMyHHxexa, noBpexyieHHa KOKH cjiyxoBoro npoxojja. BwsbiBaxb 3a6ojieBaHHe MOHCCX K3K ycnoBHO-naxoreHnaa MHKpo4)Jiopa, sacejiaiomaa
KO5Ky cjiyxoBoro npoxo^a, xaK H BHpycbi, naxoreHHwe raoepoflHbie 6aKxepHH.
O6wHHO ocxpoe HanaJio 3a6ojieBaHH» CBasano c OAHHM BHJIOM BO36y;iHxejia, a B
paarape KJIHHHKH BocnajiHxenbHbiH npouecc noaaepxcHaaexca BceM MHorooGpa3HCM npHcyxcxByromefi na Koace MHKpo(})Jiopbi, BKjnonaioiueH B ce6a BHpycw,
6aKxepHH H rpnCiKH. OopMy xpOHHHCCKoro flHtJxipysHoro napymioro oxnxa, BHSBaHHoro npeHMyiuecxBCHHO rpnGKOBOH (JmopoH, Hasbiaaiox OXOMHKOSOM. OanaKO npH oxoMHKOse HepeflKO H3 cjiyxoBoro npoxojja BbiceBaioxca cxa4)HJiOKOKKH H
cxpenxoKOKKH. 3jiOKanecxBeHHO, c pasBHxneM xoHflponepHxoHflpHxa napyxHoro
cjiyxoBoro npoxo^a npoxeKaiox napyacnbie OXHXM npn 3nuoKpHHHbix saSojieBaHHax, B nacxHocxH npH caxapHOM aHa6exe. Hx JieneHHe flJiHxenbHoe, HO Majio3<}p4)eKXHBHoe. HcxoflOM asjiaexca pasBHxne pySuoBOH fle<})opMan,HH, axpe3HH
napy>KHoro cnyxoBoro npoxoAa. Ilpn napyacHOMflH4>4>y3HOMOTHTe 6onbHbie
xcanyioxca na 6o:ib B yxe, ycHJiHBaioiuyioca npn oxKpbiBaHHH pxa. Cjiyx ne cxpa.aaex. riajibnauna Koae^Ka, oxxarHBaHHe yuiHOH paKOBHHbl 6ojie3HeHHbi. Hepe^KO
Ha6moaaexca yBejiHHCHHe H GonesneHHOCXb OKOJioyuiHbix nHM(J)axHHecKHX ysJIOB. Ilpn oxocKonHH Koxa HapyacHoro cjiyxoBoro npoxo^a nHfy$y3no rnnepeMHpOBana, oxenHa. HpocBex napy»CHoro cjiyxosoro npoxo^a cyacen, HHor^a
nojiHOCxbio oxcyxcxByex. LI,ejiocxHOCxb 6apa6aHHOH nepenoHKH coxpaneHa, UBCX
sapbHpyexca ox ceporo 0.0 pososoro H saBHCHT ox aKXHBHOCXH BOcnajiHxenbHoro
npouecca, onosnaBaxeJibKbie nyHKXbi pasJiHHHMbi.
Jlenenue. BoJitHbiM HasHanaioT aHxnSHOXHKH uinpOKoro cneKxpa jiencxBHa,
aHxnrHcxaMHHHbie npenapaxbl, ananbrexHRH. MCCXHO ncnojibsyiox KaroiH, Ma3H,
coaepacamne ropMOHbl H npoxHBOMHKpo6Hbie npenapaxbl (Ma3H TpnjiepM, THOKCH30H H x. a., KanjiH Anaypan, /JeKCOHa, Co^paaeKC, HopiwaKC H x. #.), xaicace nasnaqaexca (JmaHOJieneHHe (nepeMCHHoe MarHHXHoe none, XOKH YBM na OKOJIOyuiHyio o6nacxb).
OTOMHKOS BbiawBaiox rpn6KH po^a Candida, neHHUHJUiHHbi, aspergillus
niger. BojibHbix 6ecnoKoax sya, 6onb B yxe. Bbi^eJieHHa H3 yxa XBOpo>KHCXoro,
KpouiKOBHflHoro, raieHHaxoro HJIH cJiH3Hcxo-rHOHHoro xapaKxepa. 3a6oneBaHHe
C, HOCHX XpOHHHCCKHH, pCUHflHBHpyiOmHH XapaKXCp. JlflX
HfleHXH(J)H-
B036yflHxena npHMenaexcfl cocKoS c KOHCH Hapyxcnoro cjiyxoBoro npoxoaa na cxemio.
Jlenenue oxoMHKOsa xpe6yex HCKjnoneHHa HS nnxaHHa cnaflocxen, ocxpoft H
COJICHOH nnuiH, KpenKHX anKoronbHbix nannxKOB. Hasnanaioxca CHCxeMHbie npoXHEorpnGKOBbie, aHXHrHcxaMHHHbie npenapaxbl. Hs npoxHEorpnGKOBbix cpe^cxB
Hcnoubsyiox OJUOMHKOH, Hnsopaji, OponasoJi, HncxaxKH H x. fl. 34xJ)eKXHBHOCXb
neneHHa 3HaiHxejibHO noBbiuiaexca npH xmaxenbHOM OKCAHCBHOM xyanexe Hapy»CHoro cjiyxoBoro npoxo^a. 3jiHMHHauHio rpnGKOBoro Hanexa oSnernaex
anraiHKauHOHHaa anecxesna KOKH cnyxoBoro npoxo.ua.
OTOrEHHblE BHYTPMHEPEnHblE OCJ1OKHEHH3
159
canauHH ncnojibsyKix 3 % pacxsop nepeKHcn BO^opoaa, pacxBop ManasHxa, AKBHpHHa, MnpaMHCXHH, 3 % pacxBop yKcycnoH KHCJIOXH. 3HflaypanbHO saKJiaawBarox npoxHBorpH6KOBbie M33H JlaMH3HJi, MHKO3OHOH, Hnsopaji, KjioxpHMaaon,
HHCxaxHHOByio Ma3b. Kypc jieneHHa npoflonacaexcH 10—14flHeii. B flanbHeHiiieM
peKOMCHflyexca nepes 10-14flHeH noBxopHbiH Kypc MCCXHOFO neneHiw. BojibHHM peKOMetmyexca uinpoKoe HcnojibsoBaHHe B nnxaHHH KHCJIOMOJIOHHHX npoayKXOB, Hasnaiaiox nojiHBHxaMHHbi, pacxHxenbHbie HMMynoMOflynaxopbi.
OiKoru H OTMOpo>KeiiHH HapyiKHoro yxa. Oacor yuiHOH paKOBHHbl H napy»CHoro cjiyxoBoro npoxo^a Bcxpenaexca npn oxcorax BOJIOCHCXOH nacxn ronoBH H jiHua. BbiAenarax Hextipe cxenenn o>Kora: I cxenenb — Kowa yuiHOH paKOBHHbi rnnepeMHpOBaHa H oxenna, II cxenenb — Ha KOHCC HMeioxca nyawpn,
III cxenenb — HMeexca cxpyn Koacn, neKpos nofljiexcamnx XKaneH, IV cxenenb —
o6yraHBaHHe TKaHeB.
Jlenenue oacora yuiHOH paKOBHHbl nposo^Hxca oxKpbixwM cnoco6oM. IlopaweHHaa nosepxHOCxb o6pa6axbiBaexca nenofi HaHxeHOJi, Ojiasonb, 2 % pacxsoPOM nepManranaxa Kanna. Ha HCKpoxH3HpoBaHHbie XKann Hanocax Ma3H, cnoco6cxByiomHe OHHUICHHIO H saxcHBJieHHK) pan: HpyKCOJI, JleBOMCKOJib, MexnjiypaminoByio M33b H T. fl. Ilpn oacore HapyacHoro cjiyxoBoro npoxo^a pjvi npeaoxaxpe3HH ero fljiHxejibHo xaMnoHHpyiox MaseBbiMH xypyHflaMH.
yuiHofi paKOBHHbl name Ha6jnoflaK)xca HsojinpOBanHbie. BH4 cxeneHH oxMopoaceHHa yuiHOH paKOBHHbi: I cxenenb — Ko*a
a, oxenna, II cxenenb — na KOXCC HMeioxca nysbipn, III cxenenb —
KO5KH H HOJIKOHCHOH KUCXiaXKH, IV CXCnCHb
H6Kp03 XpaiUa yiUHOH paKOBHHbl.
Jlevenue. TLpn oxMopoaceHHH I cxenenn H MeJiKHX nysbipax II cxenenn ymnyio
paKOBHHy corpesaiox nonycnHpxoBbiM KOMnpeccoM, npn II cxeneHH, CCJIH nysbipn
BCKpwxbi, noBepxHOCxb o6pa6axbmaexca 4>ypaioinjiHHOM, HaicnaflbiBaexca acenxnnecKaa noBa3Ka. Ilpn III H IV cxeneiwx oxMOpoxceHHa noKasana rocnnxaJiHsauHa
SojibHoro, jie«eHHe" c npHMCHCHHeM anxnGnoxHROB, BasoaKXHBHbix npenapaxos.
Ocrpoe rHOHHoe BOcnajieHHe cpeflnero yxa. Bcxpenaroxca SBC KJIHHHHCCKHC <J>opMbi ocxporo rnoHHoro BocnajieHHa cpeflHero yxa: Henep(|>opaxHBHbiH
rHOHHblH CpCflHHH OXHX H nep<j)OpaXHBHbIH FHOHHUH CpeflHHH OXHX. IlepBaa
<j)opMa xapaKxepna RIM aexcKoro Bospacxa, Bxopaa Bcxpenaexca BO scex sospacXHHX rpynnax.
Ocmpbiu znouHbiu Henep<popamu6Hbiu cpednuu omum nacxo pasBHBaexca na
4>OHe ocxpbix pecnnpaxopHbix 3a5oneBaHHH. Ilpe^pacnojiaraiomHMH <J>aKxopaMH
pasBHTHa Henep<j)opaxHBHoro cpe^Hero ornxa y aereH aBJiaioxca BOSpacxHbie oco6eHHocxH cpeflHero yxa H, B nacxnocxH, 6apa6aHHOH nepenoHKH, a xaicxce xonorpa<J)HHecKHe oxHOineHHa cpeflHero yxa H opranoB HOCOFJIOXKH, BpeMCHHbie HJIH
nepMancHXHwe HMMynojie(J)HUHXHbie cocxoaHHa. C naxorenesoM cpeflnero oxnxa
XCCHO cBasana rnnepruiasHa ajjeHouziHOH xKann, Koxopaa aajiaexca «pe3HjjeHn,HeH»
naxoreHHbix MHKpoopraHH3MOB, BbiSHBaromnx cpejjHHH OXHX, cnocoGcxByex JIHC4>yHKUHH cjiyxoBOH xpy6bi. OpeHMymecxBeHHO HH^HUHposaHHe cpeflHero yxa
160
Teivia IX. 3AEOriEBAHHfl YXA.
qepes cnyxoByK) xpySy (pHHoxy6apHbm nyxb HHcJiHUHpoBaHHa). BocHflHC<J)yHKu,HacjryxoBOH xpy6w npHBOJiax K napacxaHHio oxpHuaxejibHoro /jaBJieHHa B 6apa6anHOH HOJIOCXH. B SXHX ycnoBHax MeHocnexoHHaa >KimKocxb
iipoiioxeBaex MS CJIHSHCXOH B npocsex 6apa6aHHOH HOJIOCXH, 4>opMHpya ceposHWH
BOcnanHxejibHbiH SKCcyziax. Ha SXOM axane xowKOCxb cpeanero yxa Kyjibxypono3HXHBHa B 50-60 % cnynaes, a BocnajiHxejibHbiH npouecc HMeex nepxw KaxapanbHoro BocnajieHHa. 3KCcyziax 6apa6anHOH HOJIOCXH 6bicxpo HamaHBaexca, ero
KOJIHHCCXBO yBejiHHHBaexca, flaBJieHHe na 6apa6aHHyro nepenoHKy ycmiHsaexca, a
ee npoGo^eHHH HC Hacrynaex. noBbimeHHe flaBJieHHa B 6apa6amiOH nojiocxH H oxcyxcxBHe oxxoKa raoHHoro 3Kccyaaxa npHBOAsx K nocxymieHHio B KpoBb XOKCHHOB
HS onara BocnajieHHa, HXO o6ycnoBJiHBaex pasBHXHe o6meHH<J)eKU,HOHHoro CHHApOMa, a CAaBJICHHC MHOrOHHCJICHHblX HCpBHblX OKOHHaHHH CJIH3HCXOH BbI3bIBaCX
BbIpa>KeHHbIH 6OJICBOH CHHAPOM. B flCXCKOM BOSpaCXC BCflymHlM CHHflpOMOM OCX-
poro cpeflHero OTHxa Moryr 6wxb HCHpoxoKCHHecKHH HJIH flHcnenxHHecKMH CHHapOMbi. KnHHHKa ocxporo Henep<J)opaxHBHoro cpeanero oxHxa saBHCux ox Boapacxa peSeHKa H cxenenH HHxoKCHKauHH. Y aexefi rpy^noro Bospacxa aeflyiuHM HBJWexca ^HcnenxHHecKHH CHH^POM. Pe6eHOK oxKasbmaexcfl ox eflbi HJIH cocex xonbKO
H3 OAHOH rpyflH (npoxHBonojio>KHOH 6ojibHOMy yxy), na (J>OHe JinxopaflKH BOSMOSCna nofixopnaa psoxa, acHflKHH cxyji. Pe6eHOK nocxoaHHO rpoMKO ruianex, KpyxHX
ronoBOH B cxopoHbi, pyKOH xpex 6ojitHoe yxo. /],exH 6onee cxapmero sospacxa »cajryioxca na 6onb B yxe, CHHacenHe cnyxa. flpn OXOCKOHHH 6apa6aHHaa nepenoHKa
ranepeMnpOBaHa, onosnaBaxejibHbie irynKTbi crjiaaceHbi. IlepenoHKa BbiGyxaex B
npocBex HapyxHoro ciryxoBoro npoxo^a (CM. PHC. 14 IIpHJioaceHHa).
Jlenenue. BbipajKeHHbiH SOJICBOH CHH^POM, BbicoKaa HHxoKcmcaiLHfl, noasjieHHC CHMnxoMOB pasApaaceHHa MCHHHreajibHbix o6ojioneK HBJMIOXCH noKasaHHCM
ana pacceieHHfl 6apa6aHHOH nepenoHKH. DapaueHxes 6apa6aHHOH nepenoHKH
BbinojiHHexca noa MCCXHOH aniuiHKauHOHHOH HJIH noa oGmeft anecxesHeH c noMoujbio napaqeHxesHOH HFJIM. Paspes 6apa6aHHOH nepenoHKH nposoflflT npeHMymecxBCHHO B 3aflHe-HH2(HeM KBa^paHxe HaxanyxoH HacxH napajuiejibHO 4>n6pO3HOMy KOJibiiy. C noMombro flaHHOH onepauHH o6mee COCXOHHHC 6ojibHoro
6bicxpo yjiyHiuaexca. IIoaBJiflexca OXXOK 3Kccyziaxa H3 cpeanero yxa, B CBHSH c
HCM yMCHbinaexca HHXOKCHKauna. ^aBJiCHne B nojiocxax cpeflnero yxa 6bicxpo
HOpMaJiHsyexca, HXO Kynnpyer GOJICBOH CHHjrpOM. Fpy^Hbix flexefi peKOMCH/iyiox
name Hocnxb na pyKax, ran K3K B BepxHKajibHOM nojio»ceHHH SoJib B yxe yMeHbinaexca, KopivuieHHe xaioKe npoBOJxsx B BepxHKajibHOM nojio*ennH peSenKa. 3nflaypajibHO Hasnaiaiox 0,1 % pacxsop a^penajiMHa, yiiiHbie KanjiH Ha BOJTHOH ocHOBC (FapasoH, LtynpoMea, Oxo<j)a, ^eKcona H x. fl.). B HOC Hasnaqaiox saKanbiBaHHe cocyaocy»HBaiomHX xanejib (nasHEHH, «jjJiaHoc», na<J)TH3HH H x. fl.) B noJIOXCCHHH pe6eHKa na cnnne. DpOBOflHxca CHMnxoMaxHHecKaa xepanHfl. Ilpn oxcyxcxBHH jiHxopaflKH nasHaiaiox XOKH YBH na OKOJioyuinyio o6jiacxb.
Ocmpbiu zHOUHbiu nepfiopamueHbiu cpednuu omum. B xeneHHH ocxporo
nep<})opaxHBHoro rHOHHoro cpeflHero oxHxa BbifleJiaiox xpn cxa^HH: Henep(J)opa-
OTOrEHHblE BHYTPHMEPEnHblE OCflO>KHEHH?1
161
xHBHyio, nepcJDOpaxHBHyio H penapaxHBHyio. /JjiHxejibHOCxb Henepcj)opaxHBHOH
cxajjHH o6biHHo cocxaBJiaex 3-4flHa, xoxa ee npojjoji»HxejibHocxb MOXCCX sapbHpOBaxbca ox 1-x ao 7-H cyxoK. DaxoreHes SXOH cxajjHH cooxBexcxsyex
ocxporo Henep<|>opaxHBHoro cpejjHero oxHxa c XOH pasHHtieft, MXO B
aaBJieHHa 3KCcyaaxa 6apa6aHHOH OOJIOCXH na 6apa6aHeyio nepenoHKy KPOBOCHa6)KeHHe B 6apa6aHHOH nepenoHKe yxyjiiiiaexca. Ha onpe^ejieHHOM ynacxxe
6apa6aHHOH nepenoHKH HineMHa npHBO^HX K 4>opMHpoBaHHK> onara HCKposa H
o6pa3OBaHHK) nep^opainiH — oGojjKOBOM MJIM ueH'ipajibHOH B HaxanyxoH nacxn.
B nep(J)opaxHBHyK> cxa^Hio o6mee cocxoaHHe 6onbHoro yjiynmaexca, HS yxa noaBJiaroxca cjiH3Hcxo-rHOHHbie BbijjejieHHa. B 3asHCHMOcxH ox aicxHBHOCXH BocnaHHxejibHoro npOHecca H HHflHBHflyajibHbix oco6eHHOcxefi 6apa6aHHOH nepenonKH neptj)opauHa HMCCX pasHbra pa3Mep H ^opiviy — ox xoneHHOH AO cy6xoxanbHpfi. HpH GnaronpHaxHOM Hcxojje nocxeneHHo KOJiHHecxso BbiaejieHHH H3 yxa
yMCHbiuaexca, ynyimaexca cjiyx. /IjiHxeJibHocxb nepcbopaxHBHOH cxa^HH COCXEBjiaex 1 -2 HeaejiH. B penapaxHBHOH cxa^HH npoHcxojiHX pereHepaqna 6apa6anHOH nepCHOHKH, BOCCXaHOBJICHHe (JjyHKUHH CJIH3HCXOH O6OJIOHKH BCCX nOJIOCXCH
cpeflnero yxa, BOCCxaHOBJieHne nneBMaxHsauHH cocqeBHaHoro oxpocxna. IIpoAOJiacHxejibHocxb penapaxHBHOH cxa^HH 1 -2 HCflCJiH. BjiaronpHaxHbiH HCXOA
ocxporo rHOHHoro cpeflnero oxnxa — BusAOpoBJieHHe (nojinoe BoccxaHOBJieHHe
cjiyxa H UCJIOCXHOCXH 6apa6aHHOH nepenoHKH). Ilpn nenojiHOH perenepauHH 6apa6aHHOH nepenoHKH (J>opMHpyexca cxoiiKaa nep4>opau,Ha, HXO cnoco6cxByex xpOHHsauHH rHOHHoro cpeaeero oxnxa. PasBHxne cnaeK H py6noB BHyxpn 6apa6aHHOH
nOJIOCXH npHBOJIHX K CXOHKOMy CHH5K6HHK) CJtyXa. IlpH BblCOKOH aKXHBHOCXH BOC-
nariHxejibHoro npouecca H Goraxoft nneBMaxHsanHH cocueBHanoro oxpocxna, napyuieHHH ApennpoBaHHa ajjHxo-aHxpajibHOH o6nacxH pasBHBaerca moHHoe BocnaKJiexoK cociieBH^Horo oxpocxKa — MacxoHflHX. KoHxaKXHbiM nyreM Bocnanpouecc MTOKCX pacnpocxpannxbca na BHyxpeHHee yxo c
na6HpHHXHxa, na MosroBbie o6ojiOHKH c pasBHXHCM MCHHHrHxa. Flpn caMOM
ronpHaxHOM xeneHHH saGojiesaHHa BOSMOJKCH jicxanbHbiH Hcxofl.
JJeneHue npn Heocjio>KHeHHOM xeneHHH rHOHHoro cpejjnero oxHxa KOHcepsaxHBHoe, Bbi6op npenapaxoB saBHCHx ox cxa^HH 3a6ojieB3HHa. B Henep<J)opaTHBnyio cxa^HK) HasHanaioT saKantmaHHe B yxo cnHpxoBbix pacxBopOB (JtypauHiuiHna, JieBOMHuexHHa, KaM(J)opHbiH, 6opHbiH cnnpx. fl,Jia yjiynuieHHa (JiyHKUHH cnyXOBOH xpy6bi npHMCHHiox 3HjjoHa3aJibHO cocy/iocy5KHBaiomHe KanjiH. BoJibHbiM
HasnaHaiox anxHSaKxepHajibHyio, jjeceHCH6HJiH3HpyK)inyio xepanHio, aHajibrexHKH. IlpH CXOHKOM 6oJ16BOM CHH^pOMe, 6bICTpOM HapaCXaHHH HHXOKCHK3HHH, OOaBJICHHH KJIHHHKH MaCXOHflHXa, Jia6HpHHXHX3, CHMHXOMOB paSflpa^CCHHa M03FO-
BHX o6ojiOHCK npOBOflax napauenxes 6apa6aHHOH nepenoHKH. B nep(J>opaxHBHyio
cxaflHK) iipoflojiacaexca jieneHHe aHXH6aKxepHajibHMMH, cocyjjocyHCHBaromHMH
cpejjcxsaMH, no noKaaaHHaM npoBOijHXca aesHHXoxKCHKauHOHHaa xepanaa. B
yxo Hasnanaiox anxnGaKxepnajibKbie KanjiH na BOJIHOH OCHOBC (JUnnpOMe/t, JlyiOKCHJJHH, FapaaoH). OpH Bbipa>KeHHOH oxopee span e^KeaHCBHO npOBOjjHX cyxofi
162
Teiua IX. SASOHEBAHUfl VXA.
H BJia>KHbiH xyanex napy>KHoro cnyxoBoro npoxo^a. /Jjia npOMbiBaHHa ncnojibsyrox cxepmibHbie pacxBopu (JjypaqHJuiHHa, xnopreKCHflHHa, 3 % nepeKHCH BOa, ManaBHxa, AKBHpHHa (B pasBe^eHHH 1 : 50). B penapaxHBHOH cxa^HH
6epetib yxo ox BOflbi RO nonHoro BOCcxaHOBJienHa UCJIOCXHOCXH
6apa6aHHOH nepenoHKH. UpH Heo6xo;j,HMOCxH npoBOAHxca peaSmiHxanHa cjiyxa
(npoayBaHHe escxaxHeBbix xpy6, nneBMOMacca>K 6apa6aHHOH nepenoHKH). PeKOMCH/iyexca npneivt nojiHBHxaMHHOB, aHXHOKCHaaHXOB, HMMynoMOflyriaxopOB.
MacTonaHT — BocnaneHHe CJIHSHCXOH oSojioiKH aneeK H KOCXHOH xicaHH
cocuesH/iHoro oxpocxxa BHCOHHOH KOCXH. Bbijjeuaiox nepBH^Hbre H BxopnqHbie
MacxoHflHXbi. IlepBHHHbiH MacxoH/nix BOSHHKaex 6e3 npcfliuecxBOBaBiuero ocxporo FHOHHOFO cpeflnero oxnia, BXOpHiHbiH — Ha (Jjone ocxporo Bocnajienna
cpe^Hero yxa. CHMnxoMbi MacxoH^Hxa conexaioxca c y»ce HMdomeiica KJIHHHKOH
ocxporo rHoimoro cpeanero oxHxa. K npHSHaKaM MacxoH^nxa oxnocaxca: cma3K6HHOCXb sayiUHOH CKJia^KH H OXXOnblpCHHOCXb ylllHOH paKOBHHbl Ha 6ojIbHOH
CXOpOHC, HaBHCaHHC SaflHe-BCpXHCH CXCHKH B KOCTHOH HaCXH Hapy5KHOFO CJiyXO-
BOFO npoxoaa. PeHxrenojiorHHecKH onpe^enaexca CHHaceHne npospanHocxn KJICTOK cocueBHflHoro oxpocxKa, HcxoHHCHne VUIVL noJiHoe oxcyxcxBHe MeHCtaneeHHWX neperopoaoK. Hpn paspyuieHHH KopxHKajibHoro cjioa cocqeBHZiHoro oxpocxKa H npoptiBC rnoa o6pa3yexca cy6nepHocxanbHbiH a6cuecc. V ^exen paHHero
Bospacxa cy6nepHOCxajibHbiH a6cuecc MOKCX pasBHXbca npn npOHHKHOBCHHH
rHoa nepes Hesapocmne menH 6es paspyiueHHa KOCXH. B jno6oM cnynae cy6nepHocxanbHwii aScaecc — caMbra AocxoBepHbiii npnsHaK Macxon^Hxa. Bbmejwiox
cjieayromHe (J>opMH BepxyiueHHO-uieHHoro MacxoH^nxa:
1. MacxoHflHX Beiiojibfla — MacxoH^nx, npn KoxopOM THOH npopbiBaexca
HOfl UieHHbie MblUIUbl MCpeS BHyrpCHHIOK) CXCHKy BCpXyiUKH COCIICBHZlHOrO OXpOCXKa H MO3K6X CHMyJIHpOBaXb (})nerMOHy IIICH HJIH IHCHHblH JIHM(J)aaeHHX.
2. MacxoHflHX Mype — 4>opMa, npH Koxopofi FHOH npopbiBaexca B OKOJIOrnoxoHHoe npocxpancxBo, pacnpocxpaHaexca Ha ijenb rjry6oKHx jiHM^axHHCCKHx
ysjiOB, Bbisbisaex xpOM6os JiyKOBHuw apeMHoft BCHU, a6cueccbi OKOJiorjioxoiHOro npocxpaHcxBa, MCflHacTHHHT.
3. MacxoHziHX OpJieancKoro — <j>opMa, npH Koxopofi FHOH npopbiBaexca nepe3 napy>KHyK) cxeHKy c HH({>HJibxpau,HeH XKann B o6nacxn npHKpenjieHHa rpyflHHO-KJHOHHHHO-COCUeBH^HoS MblUIUbl.
4. MacxoH^Hx ^Hxe/uiH — ray6oKHH naxeiHWH a6cuecc men, oGpaayiomnHca BCJieACTBHe npopbiBa raoa H3 nepHCHHyosnoro npocxpancxBa, Kor^a BepxymKa cocueBH^Horo oxpocxKa KomypHpyexca H flocxynna nanbnauHH.
5. SnroMaxHLiHT, CKBaMHX, nexposHX, aneijHX — ^opM1*1 MacxoHflirra npH
axnnHHHOH nH6BMaxH3aiiHH, pacnpocxpaHeHHH BOSflyxoHOCHbix aneeK B nnpaMHfly, Heuiyio, CKynoBOH oxpocxoK BHCOHHOH KOCXH. Tlpa snroMaxHiiHxe noaBJiaexca OXCHHOCTB, (JMiOKTyanHa no xojiy cKynosoro oxpocxKa. .Una nexposHxa xapaKxepen cHH^poM FpaAeHHro: ocxpbiH FHOHHUH cpe^HKH OTHX,
no xoay xpoHHHHHoro nepsa, napajiHH oxBOJjamero Hepaa.
OTOrEHHblE BHYTPHHEPEnHblE OCJlO>KHEHI/lfl
163
Jlenenue Macxonanxa KoncepBaxHBHoe H xnpyprHMecKoe. KoncepBaxHBHaa
xepanna cooxBexcxByex npHHunnaM JieneHHa ocxporo nep(J)opaxHBHoro rnoHHOro cpeanero otHxa. AScojnoxHbiM noKasaHHCM jina XHpyprHHecKoro JieneHna aBjiaroxca cySnepHocxajibHWH aScuecc, BCpxyuienHbie H arnnHHHbie <J>opMbi MacxoH^Hxa, pasBHXHe jiaGnpHHXHxa, oxorenHoro napesa Jinqcsoro nepBa, BHyxpnHCpenHblX OCJIO5KH6HHH.
CymecTByrox cue^yiouiHe BH/JH XHpyprHHecKoro BMeuiaxejibcxBa npn Macxpenanauna cocueBHjiHoro oxpocxKa c
naxonorHnecKH HSMeneHHOH XKann H /ipeHnpoBaHHa 6apa6aHHOH nojiocXH. TexHHKa onepaiiHH: sayuiHbiM aocxynoM o6Ha»caiox xpeyrojibHHK Illnno. RoJIOXOM c6HBaiOX KOpXHKajIbHblH CJIOH COCUCBHflHOrO OXpOCXKa MCJIKOH nJIOCKOH
cxpyHCKOH B npoeKujHH anxpyMa flo npOHHKHOBeHHa B nojiocxb neuiepbi (anxpoxoMHa). O6biHHO anxpyM pacnonaraexca Ha rjry6HHe 1 - 1 ,5 CM. BcKpwBaioT see
aneHKH cocueBHZjHoro oxpocxKa, narojiorHHCCKH H3MeneHHbie XKaHH yaanarox.
Ocxpoii JioacKOH pacuinpaiox BXOJI B nemepy. SaKamHsaiox onepaiinro crjia»HBaHHCM OCXpblX KOCXHblX yTJIOB H ilpOMblBaHHCM o6pa30BaHHOH nOJIOCXH paCXBOpOM
nepeKHCH Boaopojia HJIH anxnGnoxHRa. B nocjieonepaiiHOHHOM nepnoae pany BCflyx oxKpbixbiM cnoco6oM: xaMnomipyiox MapnesbiM xaMnonoM c HOflO(J)opMeHHOH,
CHHXOMHUHHOBOH HJIH HHOH 3MyjIbCHCH. B Hapy>KHbIH CJiyXOBOH npOXOJI
BBOflHXca MapJieBbiH xaivrnOH c yKasannbiMH 3MyjibcnaMH HJIH pacxaopOM
a. Hepes 7-10 aneHfla sayuiHyio pany HaioiaflbiBaiox BxopHHHbie UIBH.
MacxoHfl3KxoMH« — noJiHoe yflaneHHe cocuesHflHoro oxpocxKa. OnepaqHa
npn cy6nepHOcxanbHOM a6ci;ecce, BepxymeHHO-uieHHbix (j)opMax
MacxoHjjHxa.
• PacuiHpeHHaa aHxpOMacxoHJioxoMHJi — xpenaHauHfl BCCX aneeK COCUCBH/IHoro oxpocxKa, aonojineHHaa o6na>KeHHeM XBepaofi MOSFOBOH O6OJIOHKH H/HJIH
CXCHKH CHrMOBH^Horo CHHyca. OnepaiiHa Bbinojinaexca npn pasBHXHH oxoreHHblX BHyXpHHCpenHblX OCJIOHCHCHKH, TpOM6o33 CHFMOBHflHOrO CHHyca npH OCTpOM FHOHHOM CpCflHCM OXHXC.
XpOHMHeCKMM rHOMHbm CpeAHMM OTMT
XpoHHHecKoe rHOHHoe BOcnajieHHe cpe^nero yxa xapaKxepnsyexca nocxoaHHWM HJIH nepHO/iHHecKHM FHoexeHCHHeM H3 yxa 6ojiee mecxH ne^eJib, CXOHKOH
nep(J)opauHeH 6apa6aHHOH nepenoHKH, nporpeccnpyiouieH xyroyxocxbK). XpoHHHCCKHH FHOHHblH CpCflHHH OXHT OK33bIBaeX BJIHaHHC H3 B6Cb OpraHH3M, BblSbl-
Baa o6meHHxoKCHKaiiHOHHbiH CHHflpoM, CTOHKHC HMMyHOJiorHHecKHe HapyiiieHHa; Kapnec BHCOHHOH KOCXH o6ycjiOBJiHBaer BO3MO5KHOcxb pasBHxna BHyrpHHepennbix ocjioacHeHHH. 3a6ojieBaHHe pacnpocxpaneHO jjocxaxoHHO uinpoKO. B
cxpyKxype oxopHHOJiapHHrojiorHHecKOH 3a6ojieBaeMOcxH xponHHecKHH FHOHHUH
OXHX cocxasjiaex OKOJIO 20 %. CounajibHaa snanHMOcxb aaHHoro 3a6o-
Tewa IX. 3ABOJ1EBAHM3 YXA.
164
oGycjiOBJiena AJiHxejibHOH cpeAHeroAOBOH HexpyAocnocoGnocxbio, BH3BaHHOH nacxwMH oGocxpeHHaMH npouecca, nporpeccnpyioiueH xyroyxocxbio,
HepeAKO xpeGyioiueH cjiyxonpoxesHpoBaHHa HJIH XHpyprHHecKOH KoppeKUHH.
Tyroyxocxb, pasBHBinaaca B ASXCXBC, xpeGyex cosAaHns cneunanbHux ycJioBHii
AJia oGyneHHH peGenKa, orpaHHHHBaex BbiGop npo<JieccHH. BojibHbie xpoHHneCKHM FHOHHblM 3nHXHMnaHHXOM OrpaHKHCHHO POAHbl K CJiy^cGc B apMHH.
3XHOJIOPHHCCKHM (J)aKXOpOM B paSBHXHH XpOHHHCCKOrO PHOHHOrO CpeAHCPO
oxHxa HBJiaexca GaKxepHajibHaa H/HJIH rpnGKOBaa oGceMCHCHHOCxb nojiocxen
cpeAHero yxa, npn najiHHHH xonecxeaxoMbi naGjuoAaexca BHCOKHH npouenx anaSpoGHOH MHKpOfJuiOpbl.
CxatJjHJioKOKK aBJiaexca nanGojiee nacxbiM BOsGyAHxeneM xpoHHHecKoro rHOHHOFO cpeAHero oxnxa. B 30-50 % cjiynaeB H3 oxAejiaeMoro HOJIOCXH cpeAHero yxa
BbiceBaexcH xox HUH HHOH mxaMM naxorenHoro cxacj)HJioKOKKa. HeoGxoAHMO oxMexHXb, HXO B nocneAHee AecaxHJiexHe Bospocjia ponb BosGyAHxejiefi: Proteus
vulgaris, Pseudomonada aeruginosa, rpnGoB Candida albicans H aspergillus niger,
xapaKxepna MHKCx-HH(|)eKUHa pasJiHHHbix BHAOB Staphylococcus H Streptococcus.
XpoHHsauHH BOcnaneHHa B cpeAHCM yxe cnocoGcxByex paA snaxoMHHecKHx ocoGeHHOCxeH BHCOHHOH KOCXH. TaK, GeAHaa nneBMaxHsauHa cocuesHAHoro oxpocxK3 oGycjioBJiHBaex neAocxaxoHHOCxb <J)H3HOJiorHHecKoro npeccopuoro 6y4>ep3, 3
yxo, CKJiOHHoe K pasBHXHio oxpHuaxejibHoro r330Boro Gaimucs BCJICACXBHC neAOCX3XK3 BCHXHJLaUHH, GoJICC npeAp3CnOJIO>KeHO H K P33BHXHK) XpOHHHCCKOrO
BocnaneHHX. HajiHHne cmiaAOK H KapManoa CJIHSHCXOH, BbicxnjiaioiueH GapaGanHyK) nojiocxb, cnocoGcxByex CKomieHHio H saAepacKe B HHX 3KccyAaxa, npenaxcxsyex 3aBepmeHHK> CSHSUHH UOJIOCXCH cpeAHero yxa npn pasBHXHH rHOHHoro
BocnajieHHa. C ynexoM JIOKSJIHSSUHH npouecca, MOpiJiojiorHHecKHX H3MeHCHHH,
KJIHHHHCCKOrO XCHCHHa pa3JIHH3K)X AB6 OCHOBHHC <}>OpMbI XpOHHHCCKOrO FHOH-
•S
Horo cpeAHero oxnxa: MesoxHMnaHHX H 3nHXHMnanHX.
\H rHOHHUH Me3OTHMnaHHT xapaKxepHsyexca GjiaronpHax• HHM, AoGpOKanecxBeHHbiM xeneHHeM. IlopsxceHHe CHHSHCXOH oGojioiKH HaGnK)Aaexca B cpeAHCM H HHacncM oxAenax GapaGaHHOH HOJIOCXH. IlpH 3XOM B BocnaiiHxenbHbiH npouecc BOBJieKaexca H cjinsncxaa oGonoHKa cjiyxoBOH xpyGbi. Ilep(})opauHa GapaGaHHOH nepenoHKH pasJiHHHOH BenHHHHbi H (J)opMbi, oGoAKOBaa
HJIH ueHxpajibHaa, pacnojiaraexca B HaxaHyxofi nacxn GapaGaHHOH nepenoHKH.
BbiACJieHHa H3 yxa cjiH3Hcxo-rHOHHbie, ycHUHBaroxca npn oGocxpeHHH npouecca.
Cjiyx noHHHceH no xnny 3ByKonpOBeACHHa, cxenenb noxepn cjiyxa saBHcnx ox
noBpeacACHHa GapaGaHHOH nepenoHKH, MeMGpanbi Kpyrjioro oKHa, GjioxaAbi anxpo-MacxoHAajibHOH HOJIOCXH, Bbi3BaHHbix jiHGo ranepruiasHeH CJIHSHCXOH 060JIOHKH, jinGo pyGuoBbiMH cpameHHaMH B GapaGaHHOH HOJIOCXH.
OGblHHO XpOHHHCCKHH rHOHHblH M63OXHMnaHHX aBnaCXCS CJICACXBHeM OCX-
poro rnoHHoro cpeAHero oxnxa. HanGoJiee paHHHe HSMeueHHa nponcxoAax B
lamina propria CJIHSHCXOH cpeAHero yxa: Bospacxaex nponycKHaa KanHJiJiapnaa
cnocoGnocxb, ysejiHHHBaexca jieHKOUHxapnaa HH(J)HJibxpauHa, Hapacxaex OXCK.
OTOrEHHblE BHYTPHMEPEnHblE OCHO>KHEHHJR
165
rnnepnuasHH CJIHSHCXOH oGojioHKH GapaGaHHOH nonocxH (Ges BHCLUHHX
oGocxpenna BocnajiHxenbHoro npouecca) conpOBO>KAaexca GoJiee BMpa>KCHHWM BOcnajieHHCM B oGnacxH axxHKa, aAnxyca H aHxpOMacxoHAajibHoii noJIOCXH. OpH pCBH3HH 33AHHX OXACJIOB aXXHKa H aAHXyca y XaKHX naUHCHXOB Bbl-
aBjiaroxca q^anyjiauHH, cnaHKH, nonHnosHO HSMeneHHaa cjinsncxaa oGojioHKa,
Koxopaa xaioKe noKpusaex cnyxoBbie KOCXOHKH. 3KCcyAax, npocanHBaroiUHHca
H3 anxpOMacxoHAajibHOH nonocxn, nocxoanHO pa3Apa>Kaex cnH3HcxyK) o6onoHicy
GapaGaHHOH HOJIOCXH, Bbisbisaa B HCH yKasaHHbie Bbiuie HSMeneHHa. HaGjnoAaexca nocxeneHHoe saMemeHne nonynauHH HH(J)HJibxpHpyiomHX JICHKOUHXOB na MOHOHyKJieapHbie KJICXKH, Koxopbie ceKpeTHpyiox seiuecxBa, nanpaBneHHbie na orpaHHHCHHe xKaHCBofi AecxpyKUHH H 4>H6po3. TpaHyjiauHOHHaa xKanb pacxex, ynjioxHaexca, xepaex CBOH cocyAbi — npouecc, npHBOAamHH K 4>n6po3y H oGpasoBaHHK) cnaeK, Koxopue SHannxejibHO yxyzuuaiox (J>yHKUHio cpeAHero yxa.
' KnuHUKa. BonbHbie 5Kajiyioxca na ruoexeneHHe H3 yxa, CHHKCHHC cjiyxa.
OGbiHHo onpeAeJiaexca KOHAyKXHBHaa xyroyxocxb I-II cxeneHH. IlpH oxocKonHH
Moacex onpeAenaxbca cjiH3Hcxo-rHOHHoe oxAenaeMoe B Hapy>KHOM cnyxosoM
npoxoAe, nocxynaKDiuee HS nep(J)opauHH GapaGaHHOH nepenoHKH. OxAejiaeMoe
sanaxa He HMCCX. riep^opauna GapaGaHHOH nepenoHKH pacnojiaraexca B naxanyXOH nacxH, oGoAKOBaa HJIH uenxpajibHaa. riep<J)opauHfl MTOKCX Gbixb sanojiHena
rpanyjiauHaMH, nojiHnoM. Ha peHxreHorpaMMe BHCOHHOH KOCXH (oGbinno HCuojibsyexca npoeKuna no Illiojuiepy, Mafiepy) onpCAenaexca CKjieposnpoBaHHe
cxpyKxyp cpeAHero yxa.
XpoHHHecKHii rHOHiibiH 3nMTHMnaHHT CKHOHCH K HcGnaronpHaxHOMy xeHCHHIO. Ilpouecc xapaKxeproyexca nopa^ceHHCM He xoflbKO CJIHSHCXOH oGojiOHKH
GapaGaHHOH nonocxH, HO H Kocxnbix CXCHOK HaAGapaGaHHoro npocxpaHCXBa (axxHKa) c pasBHxneM KapHeca KOCXH, ipaHyjiauHH. Ilep^opauHa GapaGaHHOH nepenoHKH HOCHX KpacBOH xapaKxep H pacnojiaraexca B pars flacida.*jFHdHHbife*BbiAejieHHa oGbiHHO sjioBOHHbie, HXO oGycjioBjieno anaspoGHoft HH<J>eKUHeH. CHHXCHHC cjiyxa GoJiee Bbipa>KeHO, HCM npn MesoxHMnaHHxe. Tyroyxocxb KOHAyKXHBHoro xHna, oGycjiOBJiena KapnosHbiM nopaaceHneM uenn ciiyxoBbix KOCXOHCK,
pyGuoBWMH cpameHHaMH B oGjiacxH MeMGpan OBajibHoro H kpymoro OKOH, MexaHHHCCKOH GjioKaAOH nojiocxeii cpeAHero yxa rpaHyjiaunaMH, nojinnaMH, xojiecxeaxoMHbiMH MaccaivtH, CKonjieHHCM rHOHHoro oxACJiaeMoro B Kapvianax H
CKJiaAKax epitympanum. PasBHXHe npoJiH<J)epauHH rpaHyjiauHOHHOH XKaHH xecno
CBasano c npoueccoM KOCXHOH 3p03HH. C xpoHHiecKHM rHOHHbiM annxHivinaHHXOM nepeAKO conexaexca xaKoe naxojiorHHecKoe cocxoaHne KHK xoJiecxeaxoMa.
XojiecxeaxoMa npn XPOHHHCCKOM snHXHMnaHHxe oxnocnxca K BXOPHHHHM xojiecxeaxoMaM H npeAcxaBJiaex coGoft CKonjieHHe KOHuenxpHHecKH HaKJiaAbmaiomHxca Apyr na Apyra CJIOCB snHAepMajibHbix Mace, Bpacxaiomnx B GapaGaHHyio
nojiocxt nepes KpaeByio nep^opaunio HS Hapy»Horo cnyxosoro npoxoAa.
OGbiHHo xoJiecxeaxoMa HMeex coeAHHHxejibHOXKaHHyio oGonoHKy (MaxpHKc), noKpwxyio MHorocjioHHbiM ruiocKHM 3nHxeJiHCM. 3nHAepMajibHbie Maccbi xojie-
166
Tewa IX. 3AEOJ1EBAHMH VXA.
cxeaxoMbi oSmibHO o6ceMCHeHbi anaspoGHOH MHKpocJmopoH. CBOHMH <J>epMeHxaMH H BnojiorHHecKH aKXHBHHMH npo/iyKxaMH pacna^a xojiecxeaxoMa Bbisbiaaex
.aecxpyKUHio nofljiOKameH KOCXH. PaspacxaHHe xojiecxeaxoMH MOMcex npHBecxn K
nonHOMy paspymeHHK) BCBX KOCXHWX cxpyxxyp cpeflnero yxa («ecxecxBCHHaa
paflHKajibHaa onepauHa»), oGpasosaHHio CBHiya ((jwcxyjibi) B yumon jiaGnpHHT H
pasBHXHio JiaGnpHHTHxa, pasBHXHio napesa jiHueBoro nepsa.
. BojibHbie SKanyioxca na CHHHCCHHC cjiyxa, rHOHHbie BbmejieHHa H
aanax HS yxa. Hepe^KO 6ecnoKOHX myM B yxe. Tyroyxocxb KOHflyKxHBHaa HJIH CMeiuaHHaa c npeo6jiaaaHHeM KOH^yKXHBHorp KOMnoneHxa, cxenenb
xyroyxocxH ox I #0 HI B saBHCHMOcxH ox pacnpocxpaneHHOCXH KapnecHOH flecxpyKIUiH KOCXH. IlpH OXOCKOnHH B HapyHCHOM CJiyXOBOM npOXO/K FHOHHOe OXflC-
jiaeMoe c pesKHM, HenpHaxHbiM sanaxoM. IIep4>opau,Ha 6apa6aHHOH nepenoHKH
Kpaesaa, B HCHaxaHyxoH nacxH. Moryr BH3yajiH3HpOBaxbCfl nemyHKH xonecxeaXOMM. Ha peHxreHorpaMMC BHCOHHOH KOCXH onpeflenflexcx CKneposHpoBaHHe,
ynacxKH paspoKCHHfl H .aecxpyKUHH B arrHKO-aHxpajibHOH oSnacxH.
Jlenenue xpOHHHCCKoro raoHHoro cpe^Hero oxnxa saaHcnx ox KJIHHHHCCKOH
4>opMbi 3a6oneBaHH^. Ha6nK)aeHHe 6ojibHbix XPOHHHCCKHM rHOHHbiM cpeflHHM
OTHTOM noKasbiBaer HeoflHopo^HOCTb aaHHoro KOHTHHrenxa 6ojibHbix, HTO cos/iaeT
onpeaeneHHyio cjioacnocxb perynnpOBaxb H nporHOSHposaxb xe^eHHe BOcnaneHHa
cpe^Hero yxa. 3({><j)eKXHBHoe neneHHe Gojibnoro XPOHHHCCKHM rHOHHbiM cpe/iHHM
OXHXOM BO3MO»HO XOJIbKO B yCJIOBHSX flHCnaHCepHOTO Ha6jHOfleHHa OXOpHHOJia-
pHHrojiora npH coS^io/ieHHH npHHunna npeeMCTBCHHOCXH MOKay cxauHonapOM H
nojiHKnHHHKOH, nocKonbKy jieneGHbie MeponpnarHa B cxaaHH o6ocxpeHH» H peMHCCHH HanpaBJieHbi na o6myK> uenb, HO BbinonHaMX pasHtie saaa^H.
Jlenenue 6o;ibHbix XPOHHHCCKHM FHOHHWM MeaoxHMnaHHXOM npH oxcyxcxBHH qacxbix o6ocxpeHHH sa6oJieBaHHH (HC Gojiee 4 pas B roa), oxcyxcxBHH rpanyjiauHH HJIH nojiHHOB, saxpyflHHiomHx OXXOK oxaejMCMoro HS 6apa6aHHOH HOJIOCXH, ocymecxBJwexca KOHcepBaxHBHHMH cnocoSaMH. B cxa/jnio o6ocxpeHH» naSHanaiOTca npoTHBOMHKpo6Htie npenapaxw coraacno qyacxBHTenbHocxH MHKpo4>Jiopbi cpeAHero yxa, fleceHCH6HJiH3HpyiomHe cpeacxsa, HMMyHOMOflyjiaxopti
(jiHKonHfl, ajiKHMep, 3CXH(J>aH). Bojibiiioe snaneHHe HMBCX MCCXHOC JieneHHe, KOxopoe CKJiaflbiBaexca H3 necKOJibKHX axanoa: 1) xmaxejibHbiH cyxofi HJIH BJia»cHI.IH xyanex HapyxcHoro cjiyxoBoro npoxo^a; 2) aneMHaaqHa CJIHSHCTOH cpeflHero
yxa xpaHCTHMnanajibHUM HaraexaHHeM 0,1 % pacxsopa a^peHanHHa, CMasbisaHHCM rjioxoHHoro ycxba cjiyxoBOH xpy6bi; 3) BOsjiencxBHe Ha cJiHSHCxyio 6apa6aHHofi HOJIOCXH jieKapcTBCHHbiMH cpe^cxBaMH, flua 3XOH uejiH Hcnojibsyiox pasjiHHHbie npoxHBOMHKpoGnbie cpeflcxaa: flHOKcnaHH, unnpoMefl, npenapaxbl cepeSpa (noBHaproji), aHXHSaicrepHajibHbie npenapaxw, osoKHposaHHtie pacxBopw;
4) 4>H3HOJieHeHHe. B noone/june ro^bi ann canai;HH cpeanero yxa H BoccxanoBjieHHa 4>yHKUHH cjiyxoBoii xpy6bi ncnojibsyexcx xpancMeaxanbHaa ynpaBJiaeMaa
6apoxepanHs (CM. pnc. 15 IlpHJioxceHHa). C noiwombK) opHrHHajibHOH KoncxpyK, npeflJiOHceHHOH npaKTHiecKHM BpanoM-oxopHHOJiapHHrojioroM H. B. Are-
OTOrEHHblE BHVTPMMEPEnHblE OCJlO>KHEHMfl
167
CHKO, B cjiyxoBOM npoxo^e cosaaiox nepena^bi axMoc^epnoro ^aBJieHHH, Koxopwe
cnoco6cxByiox aKXHBHOMy y/iajieHHio rHOHHoro 3KCcyaaxa HS 6apa6aHHOH HOJIOCXH
H cocHCBmiHoro oxpocxKa. Mexofl nossojiaex rjiy6oKO, ao Bepxymewbix KJICXOK
cocqeBH^Horo oxpocxKa, BBoaHTb B yxo jieKapCTBCHHbie npenapaTbi. B CTa^Hio peMHCCHH HasHanaioT HPHCM anxHOKCHZiaHXOB B xeneHHe Mecaua (BHxaMHHbi C, E,
BHxaMHHHbie KOMiuieKCbi, cojiep)KamHe Zn, Se), npoBo^ax KOppeKijHK) HOCOBOFO
flbixanna, canauHK) conyxcxByromnx xpOHHnecKHX onaroB HH^CICUHH, pea6HJinxaUHIO cjiyxa, saKajiHBaHHe. ITpnflOCXHMceHHHCXOHKOH PCMHCCHH (oxcyxcxBHe rHoexeneHHa B xe^cHHe 6-H MecHU,eB) BOSMO>KHO npoBeaeHne njiacxHKH ae(J)eKxa 6apa6aHHOH nepenoHKH. Hpn nacxo peqHaHBHpyromeM xeneHHH MesoxHMnaHHxa B cxaAHK) oGocxpeHHS peKOMCHjryexcH HasHaneHHe KOM6HHaiyiH anxnGnoTHKOB c yneXOM HyBcxBHxenbHocxH MHKpotJwiopbi, a HMMyHocxHMyjiaxopbi uejiecooGpasHCH
Hasnaqaxb B cxa^Hio peMHCCHH, HXO CBasano c HHSKHMH pesepBHbiMH B03M05KHOCX5iMH HMMyHHblX KJI6XOK. XpOHHHCCKHH THOHHWH 3nHXHMnaHHX B OCHOBHOM DOA-
JIOKHX XHpyprHHecKOMy JICHCHHIO. KoHcepBaxHBHaa xepanna npHMenaexca KaK
no/iroxoBHxejibHbiH sxan /yia onepaxHBHoro BMeuiaxejibcxsa — o6menojiocxHOH
(paflHKajibHoii) onepauHH cpeflHero yxa. LJejib paflHKanbHOH onepauHH cpe^nero
yxa — canauHa OOJIOCXCH cpeflHero yxa, npo<}>HJiaKXHKa pasBHXH^ BHyxpHHepenHHX ocno5KHeHHH. IloKasaHHa AJM pa/iHKajibHOH onepauHH:
1 ) xonecxeaxoMa;
2) JiaSnpHHXHx;
3) oxoreHHbiH napes JinueBoro nepsa;
4) pacnpocxpaHCHHbiH Kapnec KOCXH, conexaiomHHCa c nojinnaMH, rpaHyjis5) axpesna Hapy^noro CJryxoBoro npoxo^a;
6) HpHSHaKH MaCXOHAHXa.
3xanw pa^HKajibHOH onepauHH ((OXKpb^biM cnoco6oM»:
1) aHxpOMacxoHfloxoMHa sayuiHbiM aocxynoM;
2) y^ajieHHe JiaxepajibHOH CTCHKH axxHKa;
3) yjjajieHHe saflHeii KOCXHOH CXCHKH napy>KHoro cjiyxoBoro npoxo^a H <J>opMHpOBaHHe eflHHOH nojiocxH HS nojiocxefi cocueBH^Horo oxpocxKa, 6apa6aHHOH
nojiocxH H Hapy>KHoro cjiyxosoro npoxo^a;
4) y^aneHHe naxojiorHHCCKH HSMenenHbix XKaHefi, peBHsna KapMaHOB snn, jia6npHHXHbix OKOH c noMombio onepaunoHHoro MHKpocKona, nponojiocxH pacxBOpoM anxncenTHKa;
5) miacxHKa Hapyacnoro cjiyxoBoro npoxoaa.
OocjieonepauHOHHyio nojiocxb pbixjio BbinojiH«K)x MapJieBbiM xaMnoHOM c
HOflCHJtopMeHHOH sMyjibCHCH HJIH pacxBopaMH aHXH6noxHKOB nepes sayiiiHyio paHy, na nepeBasKax o6pa6axbiBaioT osoHHpoBaHHbiMH pacxsopaMH, pacxBopaMH
anxHcenTHKOB.
B nacxoamee BpeMa aaHHbiH KJiaccHHCCKHH Bapnanx pa^HKajibHOH onepaijHH
«oxKpbixbiM cnoco6oM» npHMenaexca BCC peace. LUnpOKHe BOSMoacnocxH npoxn-
168
Tewa IX. 3AEOJlEBAHMfl VXA.
BOBOcnajiHTCJibHOH TepanHH no3BOJiflK)T orpaHHHHBaTb oSteM XHpyprHHCCKoro
BMeuiaTCJibCTBa, npHMenaa aiTHKoaHTpoTOMHio, 3HJxaypanbHyio pa^HKajibHyio
onepauHK) no «33KpbiTOMy THny».
B nocjieonepaiiHOHHOM nepHO,ae GonbHbiM HasnanaioT npoTHBOMHKpo6Hyio
TepanHK), HMMyHOMOjjyuflTOpbi pacTHTejibHoro npoHcxoataeHHa.
3nH,aepMH3aHHS[ HJIH py6ueB3HHe onepainroHHOH HOJIOCTH — npouecc
H, K co5KajieHHK>, He Bcer^a nonHoueHHbiH, TpeSyiomHH Bpane6Horo Ha6jnoCBoeBpeMeHHoro HasHaneHHH BasoaicraBHbix HJIH npOTHBOBocnanHTCJibHHX npenapaTOB.
CjiyxoynynujaiomHe onepanHH BbinojinaiOT Jin6o O^HOMOMCHTHO, Jin6o nepes 6 Mecflues KJIHHHHCCKOH PCMHCCHH xpOHHnecKoro rHOHHoro cpeanero OTHTa.
FIoKasaHHCM zuis cjiyxoynyHuiaiomHx onepaqHH aBJiaeTca KOH^yKTHBHaa TyroyxocTb HJIH cMeuiaHnas TyroyxocTb c npeo6naaaHHeM Kon/iyKTHBHoro KOMHOHCHTa. IJejib cjiyxoyjiynmaiomeH onepauHH — coaflaTb CBo6o^Ho KOJieSjiiomyK)ca Me\i6paHy, repMCTHHecKH saKpbiBaromyio coaep>Kamyio Bosjjyx nojiocTb, B
KOTOpyro Bxoa«T MeananbHaa CTCHKa 6apa6aHHOH HOJIOCTH, ycTbe cjiyxoBOH Tpy6w H coxpaHHBuiHeca cjiyxoBwe KOCTOHKH. FIpoBCfleHHe cjiyxoyjiynuiaiomHx
onepauHH HCBOSMOJKHO npH CTOHKOM HapyiiieHHH (})yHKnHH cjiyxosoH Tpy6u,
cpeflHHX oTHTax, OTOMHKOSC. BoapacT 6onbHoro TaioKe HMBCT
SHaneHHe B CBSSH c BospacTHbiMH HSMeneHHaMH cjiyxa. B KanecTBC TpancnuaHTaTa ^Jia cosaaHHa 6apa6aHHOH nepenoHKH HcnoubsyeTca (J)acuHH
PltC. 1 MHKpOpHHOCKOnHfl:
a
e
cpe^Haa HocoBaa paKOBHHa; 6 ycTbe Hoco-Jio6Horo Kanajia;
coycTbe raHMOpOBOH nasyxH; ^ BepxHHfl Hocoeaji paKOBHHa;
d
iiiHn HOCOBOH neperopo^KH
BHCOHHOH MblUllIbl, KOHCHblH JIOCKyT (CBoGo^HblH HJIH H3 HOaCKe), CTCHK3 BCHbl
HJIH apyrne 6HOJiorHHecKHe TKann.
n»Tb THHOB THMnanonjiscTHKH no ByjibuiTCHHy (CM. pnc. 16
Reccsstis s
Apertura sinus sphenoidalis
;
J
Sinus sphenoidatis
Meatus nasoptiaryngtrus
I THH - MHpHHronJI3CTHK3;
II THH — JiocKyr «6apa6aHHOH nepenoHKH» yKJiaflbmaeTca Ha peseuHpoBanHblH MOJIOTOHCK, MOJIOTOHKO-HaKOB3JIbHCBbIH CyCT3B EXOflHT B HOByK) «6ap363H-
nyio noJiocTb»;
III THH — JiocKyr «6apa6aHHOH nepenoHKH» yioiaflbiBaeTCfl na peseitHpoBaHHyK) H3KOB3JIbHK), H3KOB3JIbHe-CTpeMCHHOH CyCT3B BXOJJHT B HOByK) «6apa6aH-
Hyio nojiocTb»;
IV THH — cosflaHHe MaJiofi 6apa6aHHOH HOJIOCTH, B KOTopyro BXOJXST ycTbe
cnyxoBOH Tpy6bi, OKHO npeiJUiBepHH H yjiHTKH. JlocKyT «6apa63HHOH nepenoHKH»
(})HKCHpyeTCH H3 pe3CUHpOB3HHOM CTpCMCHH;
V THH — cos^aHHe peayitHpOBaHHOH 6apa63HHOH HOJIOCTH, B KOTOpyio BXOaflT ycTbe cjiyxoBOH Tpy6w H Kpyrnoe OKHO.
.'laoiipiiiniM — rpynna BocnajiHTejibHbix 3a6ojieB3HHH BHyTpeHHero yxs,
npn KOTopux HMeeTCfl orpaHHHCHHoe HJIH flH(j)(J)y3Hoe nop3>KCHHe nepH(j>epHHeCKHX peuenTopoB BecTH6yjiapHoro H cjiyxosoro 3HaJiH33TOpoe.
Ho H. B. CojmsTOBy jisfinpHHTHT
— no 3THOJiorHH (HecneuH(J)HHecKHe,
Plica sulpingupharyngi-i
Palalum moid:
Plica salpingopalatma
Ostium ptiaryngeuni tubae auditivi
Puc. 2. JlaTepajitnaa cTeHKa nojrocxH Hoca
OTOrEHHblE BHYTPHMEPEnHblE OCJlO>KHEHl/lfl
— no naxorene3y (xHMnaHoreHHbie, MeHHHroreHHbie, reMaxoreHHbie);
TOH3MJirOH® H
Tonsilgon® N
HO xeHCHHK) H Bblpa^CCHHOCXH KJIHHHHCCKHX npOHBJieHHH (oCXpbie,
Cocras H cpopwa ewnycKa
KoMfiHHuposaHHuii npenapar paciHTejibHoro nponcxowfleHHfl. Karow /yw npneMa sHyrpb 50, 100 m BO Canons.
K lOOunyKaynaKOBKe.
100 r Hancub ToH3nnroH* H cofiepKar: 29 r eoflHO-cnwpTOBoro 3KcrpaKra Althaeae radix (nopHfl a/lien) 0.4 r, Chamomillae
{UBGTOB poMaufKn) 0,3 r, Equisett herba (rpasu XBOtija) 0,5 r, Jugtandis folia (jincTteB rpeqicoro opexa) 0,4 r, Acyitlea
um (rpaebt Tbime/iHCTHUKa} 0,4 r, Quercus cortex (Kopw gy6a) 0,2 r, Taraxaci herba (rpasw oAysaHmiKa /leKapcreeHHor
CoAepwaHMe 3iaHOJia: 16,0 - 19,5 % (s oSteMHOH OTHOiuennn).
1 Apawe coflepWHT H3Me/ib>)eHHoe /isKapcTBCHHoe pacwre/ibHoe cwpbe: Althaeae radix (KopHs amen) 8 Mr, Chamomillae flores
(UBBTOB poMauiKH) 6 Mf, Equiseti herba (tpaeu xsottia) 10 wr, Juglandis folia (jiKcrbea rpeiiKoro opexa) 12 Mr, Achillea
(Tpasw Tucfl^enHanHKa) 4 wr, Quercus cortex (KopNfly6a) 4 «r,Taraxad herba (rpaau oflysaHMHKa /leKapcTBCHHor
$apM3KOJiorn4ecKoe aeMcrsMe
/iorHMecKHe caoiicTBa o6ycjiOBfleHbi 6nojiornHecxM aKTMBHUMn BemeaaaMH, axoflfliUHNw B codas npenapa
r npoTMBOBocna/iHTejibHUM H aHTHcenrHHecKHM fleHasHen. AKTHBHue HOMnoHeHTw, axoflfli^Hx B cocras npenapa
R H xsoitya cnoco6aeyiOT nosuuieHHto aKTHBHOCTH HecneL|H(t>HHecKHx (JaKiopOB aauiHru opraHH3Ha. flo^Hcaxaptiflbi,
Maoia H 4»flaBOHOMflu powauiKH, a/irefl H TbtcjtHe/fucTHHHa, T3HHHW Kopu fly6a OKasbiBator npoTHBOBOcna/tHrejibHoe fleHCTBMe
UJ3IOT oieK otHSHCToii o6oflOHKn flNxate^bHux nyrcM. Kopa fly6a, 6orarafl Ta
— Qcrpue H xpOHM4eCK«e a
^eeaHMfl eepxHHX flbtxare/ibKux nyrefi (TOMSM/IJIHT, ^
rtpH pecnHparopHHx BHpycHwx HHiJieKmisx H K3K flo
eHwe K repanwH aHTn6noTHt<aMH
flosw M cnoco6 npHMeweHMH
B ocrpuM nepMOA PUBMTHH 3a6oAe&aHHfl:
Bapooibte npn«HMaiOT
no 25 Kane/ib HJIH no 2 apawe 5 - 6 paa a fienb.
flCTH UJKOflbHOrO B03P3CT3 npHHKMaiOT
HO 15 K3ne^b VOW DO 1 flpajKC 5 - 6 pa3 B A6Hb,
fleiM AOUJKo^tHoro eoapacra npwHHMawr
no 10 Kane/it. 5-6 paa a AeHb.
fpyflHWM flfiTHM Ha3H3Ha<OT
HO 5 KaHCJlb 5-6 p33 B ACHb,
nocfie ocjiafiAeHMH ocrporM 3a6ofleiaHHn
nooie HC>ie3HOae)tHii ocrpux CHMRTOMOB:
Bapooiue npHHUManr
flerH uKontHoro eoapacta npnHHMa«T
fletH AOiUKo^bHoro eoapaaa npuHHMaiOT
M A6THM Hash 343101
fle*ieHMe ToHawiroHOM* H B re*teHHe eutl 1 mppM.
no 25 Kane^b H^H no 2
e 3 paaa B aeHt>.
no 15 «anwib H^M no I
e 3 pasa B fleHb.
no 10 Kane/ib 3 pasa B A
no 5 Kane/ib 3 pasa B fle
maruBaiOT LjeJiMKOM, He paaweBbisas, » sannaaiOT He6<xnbii)HM KO-nnNeasoH XHJIKOCTH.
npHHwctaiOT B Hepasdae^eHKOH BHAC, HCKoropoe BPBMH noAepwae BO pry, npe^e 4en npomoTHTb.
B03MOKHU a
169
e peat<u,nn.
HoBbtujeHHafl MyecTBureflbHocTb K KOMnoHeHTaM npenapara, B HacTHoaH, K pacreHHjm ceMeflaBa
Oco&ue yxasaHtui
KoM6nHau«)i npenapara ToH
UK 1. BjpautSHHo T.H., Paduui £.10., Mamaeeea A.K}3fybeKmBHQcn KOHcepsaniBHofl repanmt xpoHnnecKHx TOHSWUIHTOB y Bereft npenaparOM
Ton3«nroH H, // TesHCu AOKnaAOB IX Hanwntnwom KOHrpecca «HenoeeK H nenapaBO*, 2002. 2. lapamewto T.M., Padtfue E.fO., HomaHOea f.fi. Onur
u npenapara ToHStuiroH H y Aerefl nocw onepauHH Ha /iHM$o-moroHHOM KOflbye. // TCSHCU AOicnaAoe IX HaiiHOHUbHoro KOHrpecca <He^OBeK H
)2, 3. ffepgavee B.C. JleHeHne npenaparoH ToHSMjiroH H 6o^bHux XPOHMHCCKHM KOMneHcnpoBaHHu» TOHJM/WIHTOI*. //CM6npcK>*fi KOHCHflnym,
4(23), 2001.
XpO-
HHMecKHe, HBHbie, jiaxeHXHbie);
— no pacnpocxpaHCHHocxH socnajinxejibHoro npoiiecca (orpaHHHCHHbie,
3Hr|)4)y3Hbie);
no MOp^OJIOrHHCCKHM H3M6HeHHaM (CCpO3Hbie, FHOHHbie, HeKpOXHHCCKH6).
HanGojiee nacxo Bcxpenaioxca xHMnanoreHHbie Jia6HpHHXHXw Ha (j)OHe ocxpdro HJIH xpoHH^ecKoro rHOHHoro cpeanero oxnxa. FTpn ocxpoM THOHHOM cpeaHCM OXHXC XOKCHHbl npoHHKarox B yiiiHOH jiaGnpHHX nepes MeM6pany Kpyrjioro
OKHa HJIH HepC3 KOJIblieBH/JHyiO CBHSKy CXpCMCHH H BbI3bIBaK)X JJH4)(J)y3HbIH BOC-
najiHxejibHHH npouecc no xnny ceposnoro Jia6HpHHXHxa. ITpn xpoHHMecKOM
FHOHHOM cpeflHeM oxHxe Kapnec KOCXH HJIH xojiecxeaxoMa npHBOJxax K o6pa3OBaHHK) 4>ncxyjibi (KOCXHOFO CBHUja) B KOCXHOH Kancyjie jia6npHHxa. Oncxyjibi MOryx 6bixt eijHHHHHbiMH HJIH MHO»cecxBeHHbiMH, name Bcero JioKaJiH3yioxca B 3Mnyjie JiaxepajibHoro nojiyKpy^cnoro Kanajia. KaK npaBHJio, (jpncxyjia co cxopOHbi
nepenoHnaxoro jia6npHHxa samnmena rpaHyjwuHOHHbiM BaJioM, BCjieflcxsne nero BOcnajiHxejibHbiH npouecc HOCHX orpaHHHeHHbiH xapanxep. OijHaKo npn ne6jiaronpHflXHOM XCHCHKH BOcnajieHHH orpaHHHeHHbiH Jia6npHHXHX MOXCCX nepeftXH B flH(j)4)y3HbiH. KjiHHHKa JiaSnpHHXHxa CKJia/jbiBaexca HS CHMHXOMOB socnajieHHa cpe^Hero yxa H BecxnGyjiflpHbix, cjiyxoBbix paccxponcxB. BecxnGyJiapHbie
paccxpoHCXBa npn nopajKCHHH JiaGnpHHxa noflpoGno ocBemenbi B pas/iejie «BecXH6yjxapHbiH aHanH3axop». Tyroyxocxb npH ceposHOM jiaGnpHHXHxe HOCHX CMeuiaHHHH xapaKxep c npeo6jiaflaHHCM cencoHeBpajitHoro KOMnonenxa, cxeneni,
xyroyXOCXH SaBHCHX OX Bblpa^CCHHOCXH BOCnaJIHXeJIbHblX HSMCHeHHH. IlpH {j)HC-
xyne JiaGnpHHxa xyroyxocxb xaioKe CMemaHHoro xapaKxepa, HO B GoJibiuen cxeneHH cxpa^aex sByKonpOBeaeHne. OpnflncJxJjySHOMTHOHHOM Jia6HpHHXHxe npoHcxoflHX rH6ejib JiaOnpHHxa H pasBHBaexca noJiHax rnyxoxa.
Jletenue jiaGnpHHXHxa Bcer/ja KOMruieKCHoe. Me/iHKaMCHxosHaa xepanna nanpaBJiena na yMCHbmeHHe jjaBJieHHa BHyxpn JiaSnpHHxa, npe/rynpoKfleHHe nepexofla ceposHoro BOcnaneHH^ B raoHHoe, npejrynpexyieHHe pasBHXus BHyxpHHepenHUX ocnoHCHeHHH. C 3XOH uenbio Hcnojibsyiox aHXH6HoxHKH, flernapaxauHOHHbie,
aesHHXOKCHKauHOHHbie cpeflcxBa. XHpyprHHecKoe JieneHHe saicniOHaexcK B npoBe46HHH caHnpyiomHx onepauHH na yxe — aHTpoMacxon/ioxoMHH, pa^HKajibHOH
onepauHH cpeAnero yxa. IlpH HannnHH (jmcxyjibi JiaGnpHHxa npOBOflnxca ee njiaCXHK3 4)aCUH6H BHCOHHOH MblUIUbl HJIH KOHCCpBHpOBaHHOH KOCXHOH
BIONORICA
Xtie phytonecring company
119607 MocKBa, yn.
Ten. (095) 502 9019
http://www.bionorica.ru
POCCMH:
, A. 52
tec (095) 734 1200
E-mail: bionorica@co.ru
OroreHHbie BHyrpMHepennbie
OxoreHHbie BHyxpHnepenHbie ocjioacHCHHa npeflcxaBJiaiox cepbesnyio naxojionno Jjaace Ha coBpeMeHHOM axane pasBHXHH Me^HUHHCKOH nayKH. Flo flannbiM pasHtlX KJIHHHK OXOpHHOJiapHHTOJIOrHH, CMCpXHOCXb npH flaHHbDC OCJIOHCHCHHaX KOJI66-
Tewa IX. SAEOJlEBAHHfl VXA.
170
jiexca ox 10 % AO 50 %. IllHpOKoe npHMeneHHe anxnGaKxepHajibHOH xepanHH npHB6JIO K H3MeHCHHK> KJIHHHKH BHyXpHHepenHMX OCJKDKHCHHH, HXO C03A3CX OnpCAe-
neHHbie xpyAHocxH CBoeBpemeHHOH AnaraocxHKH. HanpHMep, SeccHMnxoMHo npoxeKaiomHH orpaHHHeHHbiH HapyacHbift naxHMeHHHrax, SKCxpajxypajibHbiH a6cuecc
H3CXO 6biBaiox HSXOAKOH npn onepau.™. AnanHS npHHHH JiexanbHOCxH 6ojibHbix c
BTO noKasbisaex, HXO B SHaHHxejibHOH Mepe ona o6ycjioBJieHa xpyAHOCxaMH paHHeft
AH3FHOCXHKH H, cueflOBaxejibHO, HecBoeBpeMCHHbiM xHpyprmecKHM JieneHHeM.
IIpoHHKHOBeHHe HH4>eKUHH B nonocxb nepena npH oxoreHHbix BHyxpHnepermbix oano>KHeHHax nponcxoAHX pasjiHHHHMH nyxaMH:
1 . KoHxaKXHHM nyxeM — no xoAy paspyuieHHa KOCXH KapnosHbiM npoueccoM.
2. Ho npe<J)opMHpoBaHHbiM nyxaM — no nepHHCBpantHbiM npocxpancxB3M,
KpOB6HOCHbIM H JIHM<J)aXHHeCKHM COCyfl3M, COCflHHfllOmHM MCXCfly CO0OH COCy-
flHcxyio H jiHM(J)axHHecKyK) cexb yxa H nonocxn nepena.
3. JIafiHpHHxoreHHbiM nyxeM — nepes BnyxpeHHHH cnyxoBOH npoxoa, 3*moJlHMfjjaXHHCCKHH H nepHJIHM(j)aXHHeCKHH npOXOKH.
4. FeMaTOreKHblM nyXCM - npH JlHCCCMHHaUHH HH(j)eKllHH no KpOBCHOCHblM
5. JlHMtJjoreHHbiM nyxeM — npH aHcceMHHauHH HH^CKUHH no JiHM(J>axHHeCKOH CCXH.
OTOrEHHbIM PA3J1UTOM THOMHblM MEHMHrMT
KjiuHum. Ha (Jione BocnaneHHa cpe^Hero yxa pasBHBaexca cnnbHaa roJioBHaa
6ojib. Ee npHiHHa — noBbimenne BHyxpHnepenHoro AaBJieHHa, pacxa>KeHHe M03roBbix oSojioHCK H pasflpaaceHHe OKOHiaHHH TPOHHHHHOFO nepsa. Bo3Mo>KHbi
xoiiiHoxa H psoxa, HC CBasaHHbie c npiieMOM nHmH. XapaKxepna rnnepHyBcxBHxenbHocxb K 3ByKOBOMy, xaKXHJibHOMy H CBexoBOMy pasflpaHccHHio. O6mee coCXOSHHC 6ojibHoro 6ucxpo yxy^uiaexca ^o Kpafine xa^KCJioro. Hacxynaex cnyxaHHOcxb cosnaHHa, BO3MO»ceH 6pe^. Jlnxopa^Ka xnna continua, ^ocxHraioiuaa
39-40 °C H Bbiuie, nyjibc nacxwH. Hepe^Ko 6ojibHofi JICXCHX B nose «jieraBOH co6aKH» («opy>KeHHoro Kypica») — Ha 6oKy c sanpoKHHyxofl nasaa FOJIOBOH H cornyxbiMH HoraMH. IlojiOHCHxejibHbi MCHHHreajibHbie snaKH: cHMnxoMbi KepHHra,
BpyasHHCKoro, HMeexca pnrH«Hocxb saxwjioiHbix Mbiuia. B nepH(j)epHMecKOH
KPOBH Ha6jiKxaaexca BHCOKHH JiefiKounxos, ycKOpeHHe CO3. CnHHHOMOsroBaa
5KHflKOCXb Myxnaa, Hcxexaex noa aaBJieHHCM, yBCJiHHHBaexca ^o coxen H xwcan
UHXOS, KJiexoHHbiH cocxaB npeflcxaBJieH npeHMymecxBCHHO HeHxpo(J)HJiaMH, ysejiHHeno coflep»caHHe 6ejnca. IIoiioacHxejibHbiMH cxanosaxca moSynHHOBwe peaKUHH FlaH^H H HoHHC-Anenbxa. B cnHHHOMOsroBOH »CHIIKOCXH o6Hapy5KHBaK>x
MHKpo4wiopy, pmenxHHHyio MHKpo4>Jiope cpeflHero yxa.
OTOrEHHblE ABCUECCbl MOSPA M MO3MEMKA
A6cueccbi Mosra H3H6onee nacxo jioKajinsyioxca B BHCOHHOH aone FOJIOBHOro Mosra OKOJIO KpbiiiiH 6apa6aHHofi nojiocxn KUIH anxpyivia. A6cueccbi MOsacenKa
aBjiaioxca cneflcXBHCM rHOHHoro na6HpHHXHxa HJIH xpOM6o(J)Jie6Hxa
OTOrEHHblE BHVTPHHEPEnHblE OCJIOXHEHUH
171
CHHyca. A6cuecc MOWCX Gbixb orpaHH^eH
HOH KancyjioH, HO BOSMOHCHO H oxcyxcxBHe Kancynu, xorfla nonocxb aScnecca
OKpyacena paaMarneHHbiM MosroBbiM BemecxBOM. KnHHHKa onpe/tenaexca noKaHH3auHeH, BCJIHHHHOH aScuecca H cxa/weft nponecca:
I. HananbHaa (anue^ajiHXHHecKaa) cxa^Ha. /JjiHxejibHocxb l-2HeaejiH.
EonbHoro 6ecnoKoax Banocxb, nocxoanHaa rojioBHaa 6ojib, xomnoxa, psoxa.
II. JlaxenxHbiH nepHoa. fluHxejibnocxb ox 2-x «o 6-H He^eiib. CHMnxoMbi
npaKXHMecKH oxcyxcxByrox.
III. flBHaa cxaflHa. DpoAOJiacHxejibHocxb ox HecKontKHx AHCH ^o 2-x Heflenb.
XapaKxepnayexca MHoroo6pa3HCM CHMHXOMOB, Koxopbie npHHaxo paa^ejiaxb na
rpynnbi:
1) o6meHH(})eKnHOHHbiH CHHflpoM (sajiocxb, anopeKCHa, JiHxopaaKa, AHcnenCHa, jiSMeneHHa reMorpaMMbi H x. A.);
2) o6mHe MosroBbie CHMnxoMbi (ronoBHaa Sojib, MCHHHreanbHbie SHSKH,
6paAHKapaaa Ha 4>OHC nHxcpa^KH, HSMeneHHa rjiaanoro flna);
3) HapyineHHe 4>yHKu,HH nojjKOpKOBWx a^ep H npoaoflHUKOBbix HepBHbix nyxefi (reMHnapesbi H3 npoxHBonojio>KHOH 36cueccy cxopoHe, nHpsMHflHbie CHMnxoMbi OnneHreHM3, BsQHHCKoro, cyAOpora, nspsJiHH jiHuesoro Hepsa no UCHxpanbHOMy xnny);
4) rnesAHbie CHMnxoMbi, yKaabisaiomHe na noKanHsauHio a6cuecca.
ITpH pacnojiOHceHHH a6cuecca B 33AH6M OXACJIC jieaoH BHCOHHOH AOJIH y
npaaiiiH pa3BHBaexca aMHecxHMCCKsa 3(J>a3Ha — noxepa cnoco6nocxH Hasbieaxb
npCAMCXbl CBOHMH HMBHaMH. BM6CXO Ha3B3HHa npCAMCX3 6onbHOH OHHCHBaeX
ero npeAHasHSHCHHe. IIpH JIOKSJIHSSUHH sScuecca B saaneM oxAene BepxHen BHCOHHOH H3BHJIHHH (ncHxp BepHHKe) pa3BHBaexca cencopnaa a(j)a3Ha — 6onbHOH
HC noHHMaex cKasannoro, xoxa cnyx y Hero HC Hapyuien. Penb 6onbHoro npeBpaujaexca B 6eccMbicjieHHbiH na6op CJIOB. B csasH c SXHM B03HHKaex ajieKCHa H
arp3<J)Ha. y JICBUIH aHanorHHHbie HspymeHHa paaBHsaioxcfl npn a6cuecce npssofi
BHCOHHOH AOJIH. Ilop3)KeHHe np3BOH BHCOHHOH AOJIH y Ilp3BIIIH npOXCKaCX np3KXHH6CKM GeCCHMnXOMHO. Bo3MO)KHO p33BHXH6 BHCOHHOH 3X3KCHH (6ojIbHOH na-
Aaex BJICBO), rojiOBOKpyHceHHa, BecxH6yjiapHbix paccxpoficxB. Dpn a6cnecce
MO3)KeHKa xaiOKe pasBHBaioxca BecxnGyjiapHbie psccxponcxBa (onncaHbi B pa3Aejie «BecxH6yjiapHbiH aH3JiH33xop»), BbiaBJiaexca SAHSAOXOKHHCS.
IV. TepMHH3JIbH3a CX3AH8. /],JIHXeJlbHOCXb OX HCCKOJIbKHX H3COB AO HCCKOJIb-
KHX AHeft, 33K3HHHB3exca jiexaribHbiM HCxoAOM. B 3xox nepHOA napacxaex OXCK
Mosra, pasBHBaexca napannn HCHsneHHO Ba>KHbix opranoB.
OroreHHbiH cencuc. TeHepanHsauHa THOHHOH HH^CKUHH npn ocxpoM H xpoHHHecKOM oxHX3x pasBHBaexca Hsuje Bcero npH xpOM6o(J)jie6Hxe BCHOSHWX cHHyCOB: CHFMOBHAHOrO, K3MCHHCXOrO, JiyKOBHUbl apCMHOH BCHbl
HOSAHaa (})OpMa
oxoreHHoro cencHca. y MOJIOAHX JHOACH MOJKCX BO3HHK3Xb cenxHHecicaa peaioiHa c
nepBbix AHCH ocxporo oxnxa 6e3 pasBiixna xpOM6osa seHOSHbix nasyx — pannaa
4»opMa oxoreHHoro cencncs (KepHepOBCK3a (J>opMa). B OCHOBC KepHepoBCKon
TeMa IX. SABODEBAHHfl YXA.
172
(popMbi oxoreHHOro cencHca JICXCHX xpoM6o<pne6HX MCJIKHX BBH cocneBHJiHoro oxpocxKa npn MacxoH^Hxe na (pone HSMeneHHOH HMMyHOJiorHnecKOH peaKXHBHOCXH
opraHHSMa. IIporHos paHHCH (popMbi oxoreuHoro cencnca oxHOCHxenbuo 6jiaronpHHXHbiH, npn JieneHHH ona cpasHHxejibHO Jierco oSpaxHMa. CHMnxoMH OXOXCHHOFO cencHca MOJKHO paaflejiHXb na ABC rpynnbi: o6mHe H onaroBbie.
O6ufue ciwnmoMbi — reKTHHecKaa xeMnepaxypa c O3Ho6aMH H nponHBHbiM
noxoM, 6jieAHOCxb HJIH seMJiHcxocxb KO>KH, HKxepHHHOCxb cicnep, HSMeHCHHe reMorpaMMbi.
Onazoebie cuMnmoMbi:
• CHMOXOM FpHsenrepa — oxennocxb H 6ojie3HCHHOcxb npn nanbnaiiHH saflnero Kpaa cocueBHAHoro oxpocxKa, cooxBexcxByiomero Bbixo^y 3MHCcapnbix BCH.
• CHMUXOM YaHXHHxa — rojiOBa 6ojibnoro HaKnoHena B nopaaceHHyro cxopony. IIpH najibnau,HH B/joJib nepeanero Kpaa rpyaHHOKJiiOHHHHOcociieBHflHOH
MblUIUbl B03HHKaCX GoJICSHCHHOCXb.
• CHMOXOM Oocca — npn aycKyjibxauHH BHyxpeHHCH apeMHOH BCHH
oxcyxcxsyex BCHOSHbiH uiyM.
IIpHHUHnbi JieneHKH oxoreHHbix BHyipHHepenHbix OCJIOHCHCHHH CKJiaflbisaioxcfl HS xHpyprHHecKoro BMeiuaxeubcxBa H MaccHBHOH auxnGaKxepHajibHOH xepanHH. DapajiJiejibHo npOBOflHxca nocHHflpoMHaa xepanna.
XHpyprHHCCKoe BMemaxcJibcxBO npn BHyxpHHepeiiHbix OCJIOXCHCHHHX no^pa3yMesaex npOBe^euHe pacuiHpeHHOH aHxpoMacxoH^oxoMHH (npn ocxpoiw npoqecce) HJIH pacuiHpeHHOH paaHKajibHOH onepauHH (npn XPOHHHCCKOM FHOHHOM
CpCAHCM OXHXC) C o6HaaceHH6M HSMCHeHHOH M03TOBOH o6oJIOHKH. HpH H3JIHHHH
a6cuecca jjonoJiHHxenbHO npOBOflHxca ero nyHKuna H ^peHHpOBaHHe. Hpn oxjjaJICHHOM pacnoJio»ceHHH a6cuecca (BHyxpHMOsroBOH, KompJiaxepajibHOH JiOKajiHsaiiHH) SOJIBHOH nepeBOflHxca B KJIHHHKy ueHpoxHpyprHH. FIpH oxoreHHOM cenCHCC onepaiiHio Aononrauox o6Ha»ceHHeM CXCHKH CHrMOBH^Horo CHHyca, ero
nyHKU,HeH, npn HeoSxoflHMOCXH HCceneHHCM H yaaneHHCM xpoMGa.
MejiHKaMeHxosHaa xepanna BKJiiOHaex B ce6a MaccHBHbie
KOB H npoxHBorpH6KOBbix npenapaxoB, aeraApaxauHOHHbie,
Hbie cpejjcxBa, Aesarperanxbi, CHMnxoMaxHHecKHe cpeAcxsa.
Bonpocbi nna uToroeoro KOHxponn 3H3HMM no rewe IX
1. KaKMe dpaKxopbi flBnflKDTCfl HanGonee MBCXOM npuMUHoii
xoHflponepnxoHflpnxa yujHoii paKOBMHbi?
2. KaKne M3MeHeHMfl Ha6nioflaK)TCJi B 6apa6aHHoii nepenoHKe npn
ocrpOM HenepcpopaxMBHOM THOMHOM cpeflneM oxuxe?
3. KaKne BbiflerwioT craflMM B xeneHnn ocxporo rHOiiHoro cpeflHero
oxuxa?
4. KaKoe Mox<eT 6bixb ncxofl ocxporo motiHoro cpeflHero oxuxa?
5. KaKOBbi noKaaaHMH flnn xnpyprnMecKoro ne^envta Macxonflnxa?
6. B new aaimioHaexcfl couManbHoe 3HaM6Hne xpoHnsecKoro THOMHOro cpeflHero ornxa?
OTOrEHHblE BHVTPMMEPEnHblE OCnOXHEHM?!
7. KaKOBbi noKaaaHMH flnn npoBefleHun paflUKa/ibHOM onepaqnn Ha
yxe?
8. KaKOBbi noKaaaHMH flna napaqenxesa 6apa6aHHoti nepenoHKM?
9. rioneMy cnyxoynynujaioiMMe onepaqMM ne noKaaanbi no>KnnbiM
aflatouiMM xyroyxocibio?
10. flepeMncriMTe ocHOBHbie cnHflpowbi, xapaiaepHbie flnn a6ct(ecca
BMCOHHOM flOJlH MO3ra.
173
I. BocnannTenbHbie saBojiesaHna ropraHU
175
I. BOCnAJlMTEJlbHblE 3ABOJ1EBAHMJ1 TOPTAHM
Ocrpbiii JiapHHruT — HH^eKUHOHHo-anjieprHHecKoe BOcnaneHHe CJIHSHCTOH oSonoHKH H Mbiiuii ropxaHH. OcxpbiH napHHrHT HaH6ojice qacxo aBJiaeTcx
oflHHM H3 npoaBJieHHH OPBH (naparpHnna, rpHnna) H conexaeTCH c BOcnaneHHCM CJ1H3HCTOH o6ojIOHKH TpaXCH (oCTpWH JiapHHrOTpaXCHx), CJIH3HCTOH HOCE,
eis/ia X.
3AEOJ1EBAHMH TOPTAHM.
onyxoiiM JIOP-OPTAHOB
— 180
Hsynnxb icnMHMKy, fluamocTHKy n
3a6oneBaHMM ropxaHM. HayHHib ocHOBHbie CMwnxoMbi onyxo/ieti JlOP-opraHOB.
Ue/ib
1. Paso6paxb KjiMHMMecKne ocoSem-iocxM aaSoneeaHMM ropraHM.
2.
HayHMTbCfl
flMCpCpepeHUMpOBatb
HCTMHHblPi
M
no>KHbiM Kpyn.
3. OsHaKOMMTbcsi c coepeMeHHbiMM cpapMaqeBTMMeCKMMM npenapaxaMM ana nevema BOcnajimenbHbix aaGojiesaHHM ropiaHM.
4. OSHaKOMMTbCH C KJIHHMHeCKHMM OCO6eHHOCTHMM
onyxonefi JlOP-opraHOB.
OcHaujeHMe. OcBeTMxeribHbie npn6opbi: MCTOMHMK
csexa, no6Hbiii pecfuieKTOp. fleMOHCTpaunoHHbiii Maiepna/i: njiaKaibi, cnatiflbi.
Ha6op MHCTpyweHTOB. Hocosbie aepKana, liinareJIM, HOCornoTOMHbie 3epKana, soHflbi Hasi/iBHbie, nnHqeibi
HOCOBbie.
Pa6oMee MCCTO. HHcrpyMeHTa/ibHbiM CTO^MK, Hajiaivina, cnnproBKa, flsa ciyna.
MecTo npoeefleHMfl aaHnrnn. YMe6Haji KOMHara.
jinreparypa:
1. Condamoe kl. E. JleKqHu no OTOpm-ionapMHronomn. — M.: MeflMquHa, 1990.
2. LUeepbizuH 5. B. PyKOBOflCTBO no flercKoii oropnHonapuHro/iorMM. — M.: MeflMquHa, 1985.
3. Oao/ibuoea E. C., MamnxiiH E. r. flnamocTMHeH raKTMHecKMe oujn6KM npki paKe ropraHM. — M.:
1989.
moTKH H xpaxeH (pHHO-cfiapHHro-jiapHHro-TpaxeHT). BaKxepHanbHbiH ocxpbift naPHHFHX BH3biBaex npeHMymecxBCHHO KOKKOBax (Juiopa HUH canpo<j)HXbi abixaxenbHbix nyxen, naxoreHHOcxb Koxopwx eospacxaex npn XHMHHCCKOM, xepMHHeCKOM pasflpa>KeHHH ropxaHH HUH o6meM nepeoxna»cfleHHH opraHH3Ma, fljinxejibHOH rojiocoBOH narpysKe HUH pa6oxe B ntuibHOM, cyxoM noMemeHHH. B 3xnx
CJiynaax ocxpufi napHHrnx Mowex npoxeKaxb H30JiHpOBaHHO.
Ha ocxpoe aocnaneHHe ropxaHH yKastreaiox acano6bi na 6onb B ropjie, OCHHJiocxb rojioca, Jiaiomnfl Kamenb, o^biiiiKy. Hpn JiapHHrocKonnH cjiHsncxaa
Ka ropxaHH ancJwJjysHO rHnepeMnpOBana, oxenna. HcxHHHbie roJiocoBbie
posoBtie HJIH rnnepeMHpoBaHbi, OXCHHU, npn (J)OHaHHH CMtiKaioxca ne HOUHOCXBIO.
Hnorfla na HCXKHRMX ronocoBbix CKiiaflKax HMeroxca KpOBOHSJinaHHa.
Y jjexeH Mnafliuero Bospacxa Ha <})OHe ocxporo JiapHHrnxa nepeflKO pasBHBaexca noxcHbiH Kpyn — ocxpwH cxenos ropxaHH, oGycuoBjieHHbiH oxeKOM CJIHSHCXOH o6onoHKH no/icKjiajioHHoro npocxpancxBa ropxaHH. Y Bspocnwx 3x0 cocxoflHHe name Bcero csasano c OXCKOM KBHHKC. KnHHHica JIOHCHOFO Kpyna pa3BHBaexca KpaftHe Gbicxpo — B xeneHHe necKOJibKHX nacoB HJIH MHHyx. floaBJiaexcfl
HHcnnpaxopHaa oflwuiKa, Abixanne cxaHOBHXca SBynnbiM, cxpHfloposHbiM, Kauienb rpoMKHH, FOJIOC pe6eHKa pesKO rpy6eex, HO He xepxex CBOCH 3ByMHOCXH,
Bospacxaer 6ecnoKOHCXBO, Koxopoe Sbicxpo ycHJiHBaex flbixaxejibnyio HeaocxaxoHHOcxb. FIpH HO5KHOM Kpyne napHHrocKOHHa HMeex xapaKxepnbiH BH/J: npoCMaxpHBaioxca see xpn 3xawa ropxann (npHsnaK KHiuiHaHa — «paccnoeHHe»
CKJiaflOK H noflCKJiaflOHHoro npocxpancxBa). JIoacHbiH Kpyn — cocxoaHHe, xpe6yiomee OKasanna HCOXJIOHCHOH noMomn. AJIH cnaxna noacioiaAOHHoro oxeKa
ropxaHH BHyxpHMbmieHHO HJIH BHyxpHBCHHO BBOflaxca aHXHracxaMHHHbie npenapaxbi, 3y4>HJuiHH, cxepon^Hbie ropMonw.
OcxpbiH jiapHHFHx 6es cxeHosa ropxaHH noJtnejKHx jieqenHio B aMGynaxopHHX ycJiOBHax. BojibHHM Ha3Hanaiox FOJIOCOBOH pe»HM: paspemaiox pasroBapnBaxb B nojirojioca (ne uienoxoivi!) B nepByio noJiOBHHy ana, coSjuoaaa MOJiHanHe
BO Bxopyio nojiOBHHy JJHS. PeKOMCHflyexca ma^amaa flnexa c HCKJHOHeHHCM roPHH6H, XOJIO/IHOH, OCXpOH, COJICHOH HHUIH. B JlCHeHHH OCXpOFO JiapHHFHXa 3HXH-
6noxHKH Hcnojibsyiox pe/jKO — npn HanHHHH FHOHHUX Hano»eHHH na CJIHSHCXOH
ropxaHH, FHOHHOH MOKpoxbi H3 HHacHHX flbixaxeJibHbix nyxcH Ha (Jjone rnnepeprHHecKOH peaKUHH opraHH3Ma. npeflnoHXHxejibHO Mccxnoe HcnojibsoBaHne aHXH6HOTHKOB B BHflC CHpCS, HHFaJiaUHH HJIH BJIHB3HHH B FOpXaHb. Ha3HaHaiOX aH-
XHFHCxaMHHHbie openapaxw. ^exaM MJiafluiero Bospacxa, CKJIOHHHM K SponxoHasHanaiox BHyxpb 3y(J)HJiJiHH B pasoBOH aose 4 Mr/Kr 4 pa3a B
176
TeMa X. SAEOJlEBAHHfl TOPTAHH. OnyXOflU JlOP-OPrAHOB
b. Hs npoxHBOBOcnajiHxenbHbix npenapaxoB ncnojibsyiox xaftjiea,
acnnpHH H apyrae cpe^cxBa. OOaaaxejibHO Haanaqaioxca npoxHBOKauiJieBbie npenapaxbi. FIpHHCM cpe^cxsa, noflaBJiaromHe KaimieBOH pecJuieKC (xycynpeKc, JIH6eKCHH, KOflenaK, 6pOHXojiHXHH), uejiecoo6pa3HO ncnojibsoBaxb B nepswe 2-3
3a6ojieBaHHa, K0r,aa Kaiuejib cyxoft, HsnypHxejibHbiH, 6one3HeHHbiH. HpH noMOKpoxbi CJieflyex Hasnanaxb npenapaxw, cxHMyjrapyiomHe Kaiuejib (xo
ecxb — flua Kaiiijia): GpoMreKCHH, xa6nexKH xepMoncnca, oxsap Kopna COJIOAKH,
jiHcxbeB Maxb-H-ManexH, rpyflHOH c6op, MHKcxypy HOflH^a Kajina H x. fl. Y aexen
paHHero H MJiafluiero Bospacxa /JJIH KynnpoBaHHa H npo<J)HJiaKXHKH aBJieHHH cxeHosa ropxaHH npoBOAflx HHranauHOHHyio xepannio Hepes HeGyjiafisep c HcnonbsoBaHHCM P-MHMCXHKOB, KPOMOHOB, cxepOHflHbix ropMOHOB. Rim BJiHBaHHH B
ropxaHb BspocjibiM acnojibsyiox 1 % MacjiaHbiH pacxBop MeHxona, aHXHSnoxHKH,
cocy,ziocy}KHBaK>iHHe cpe^cxaa, ropMOHbl. IHnpoKO Hcnonbayexca oxBUCKaiomaa
xepanHa — ropanne HOXHWC saHHbi, ropHHHHbie o6epxwBaHHa HKpono>KHbix
Mbllim H X. R.
ropraHHan aHi Una — HH(j)eKUHOHHO-ajijieprHHecKoe BOcnaneHHe JiHM(J)OHflHOH XKaHH ropxaHH (ropxaHHbix 5Kejryao4KOB, rpyuieBHAHbix CHHycoB, MOKHepnajiOBUflHoro npocxpancxBa, Hepnano-HaflropxanHbix CKJiaflOK). 3xHonaxoreHC3 ropxaHHOH aHFHHbi He oxjiHHaexca ox ocxporo HecneHHqjmHecKoro xoHSHJiJinxa apyrHX
KOMHOHCHXOB HHM(})afleHOHflHoro rjioxoHHoro KOJibqa, oflnaKO JioicaJiioauHa B ropxaHH HaH6onee XOHHO oxpaacaex HasBaHHe saSojiesaHHa (ox ango
BojibHbie ropxaHHOH anrHHOH Hy^maroxca BO BpaneGnoM HaSjno^eHHH B
BO3MO>KHoro pasBHXHa ocxporo cxenosa ropxann. IlpH GnaronpnaxHOM x
3a6oneBaHHe saKannHBaexca nepes 6-8 aneH. OcnoxneHHeM ropxaHHOH
aBJiaexca (JjJierMOHOSHbiH jiapHHrax, pasBHXHe a6ciiecca HaaropxaHHHKa.
AScuiecc Ha;iroprannnKa — o^Ha H3 pa3HOBHflHOcxeH (J)iierMOHO3Horo JiapHHrHxa. SnHmoxxHx H a6cue,ziHpOBaHHe HaAropxaHHHKa xapaKxepnsyexca BHpaaceHHOH HHXOKCHKaHHen opraHHSMa, PCSKHMH 6ojiaMH B ropue, B03MO>KHo pasBHXHC ocxporo cxeHOsa ropxaHH. IlpH HenpaMOH napHHrocKOHHH cjinsncxaa JienecxKa HaaropxaHHHKa, nepnajio-HaAropxaHHbix CKJiaflOK, BecxnGynapHoro oxflejia ropxaHH oxenna, apno rHnepeMnpoBana. Ha noBepxnocxH nenecxica najiropxaHHHKa HMeexca BOSBWUICHHC c McenxoBaxofi BepxyuiKoii. Ilpn a6cuecce HaflropxaHHHKa noKasaHO onepaxHBHoe jieneHHe. A6cuecc BCKpusaiox ropxanHbiM
I. Bocna^MxenbHbie 3a6oneBaHMfl ropxaHM
177
npoqecca rHOHHq-HCKpoxHHecKHe Maccw no MOKXKaneBbiM menaM Moryx /jocxHHb
. B jieneHHH (J)jierMOHO3Horo napHnrnxa Hcnonbsyiox Momnyio anxHxepannio (KOM6HHauHio aHXH6noxHKOB), npoxHBooxenHyio xepa(aHXHXHCxaMHHHbie, aenHuipaxHpyiomHe cpe^cxsa, KopXHKocxepoH^bi). OpoTHOS saOoncBaHHa BO MHOTOM saBHcnx ox xa>KecxH pasBHBiuHxca OCJJOXCHCHHH.
XoHflponepnxoHflpHT ropraHH — BOcnaneHHe HaaxpamHHiibi H xpameft ropxaHH. IlepBHMHbiH xOHjjponepHxoHjipHx pasBHBaexca npn xeMaxoreHHOM nponnKHOBCHHH HH(j)eKH,HH, BXOpHHHblH XOH^pOHepHXOH^pHX - npH KOHXaKXHOM p3C-
npocxpaHeHHH HHc[)eKHHH co CJIH3HCXOH oGoJiOHKH Ha Ha^xpaiUHHuy. Hacxo nepHxoHapnx conyxcxByex onyxojin ropxaHH. ITpHHHHOH nepHXOKWpHxa MOJKCX 6bixb
xpaBMa ropxaHH. Ilo cpoKaM pasBHxna Bbmcnaiox ocxpwe H xpoHHnecKHe nepnxoH^pHXbi. Flo cxeneHH pacnpocxpaneHHocxH — orpaHHwenHbie H pasjiHXbie.
Bcxpenaroxca ppe Mop(J)OJiorHHecKHe (j)opMbi nepHxoHflpnxoB — raoHHaa H CKJICpo3npyiomaa. Ilpn THOHHOH <j)opMe HaicanjiHBaiomHeca rHOHHbie Maccbi oxcjianBarox xpam ox HaflxpamHHijbi. JlHiueHHbiH nnxaHHs xpam 6bicxpo pacnnaBJiaexca c
o6pasoBaHHeM CBHmefi, nepes Koxopbie Moryx Bbwejiaxbca ceKBecxpw xpama. IlpH
CKjieposHpyiomeH (Jjopvie HaraoeHHa ne nponcxo^Hx: HH^HiibxpaiiHa xpama BH3WBaex pocx rpaHyjiaiiHH, pa3BHxne CKnep03a, HXO npHBO^HX K CXOHKOH fle4>opMaUHH xpamefi ropxaHH. KoHCepBaxHBHoe JieneHHe xoHflponepHxonapHxa ropxanH
cooxBexcxByer neneGnbiM MeponpnaxHaM npn (|)JierMOHO3HOM JiapHHrnre. Ilpn
pasBHXHH cxenosa ropxaHH no noKasannaM npoBOflax xpaxeocroMHio.
/ln(J)TepnH ropraHH (HCTHHHLIH Kpyn). Iloflpo6Hoe onncaHHe 3xnonaxoreH633 flH<J)XepHH HMCCXCa B KypCC HH(j)eKUHOHHI>IX GOJICSHCH. Mbl npHBC^eM JlHIUb
KJiHHHHecKHe oxjiHHHa flH(j)xepHH ropxaHH ox no»Horo Kpyna. HCTHHHHH Kpyn
pasBHBaexca B xeneHne HecKOJibKHx flHen. Bbiflejiarox xpH cxaflHH HCXHHHOFO
Kpyna: aHC<J)OHHHecKyio, cxaanio Kpynosnoro Kamjia, cxenoxKHecKyio, ac<J)HKXHnecKyio. fljia HCXHHHoro Kpyna xapaKxepna nocjieaosaxejibHOCXb pasBHxna CHMnxoMOB: oxpnnjiocxb rojioca nporpeccnpyex %o a<J)OHHH, na (J)OHC AHC<}>OHHH noaBJiaexca xpHnnwH Kamenb. KpynosHbiH Kamenb (rpoMKHH BHanane) nocxeneHHO
cxanoBHxca 6e33ByMHbiM, nporpeccHpyromaa a(J)OHHa conpoBO^yjaexca HapacxaHHCM KHHHHKH cxcHosa ropxaHH. TepMHHajibHaa cxaflna cxenosa ropxaHH — ac<j)HKcna, na 3XOM (J)OHe nacxynaex CMepxb.
XpoHnnecKne BocnannrejibMbie 3a6oneBaHMfl ropraHM
HO5KOM. JICHCHHe flOHOHHaiOX aHXHgHOXHKaMH, npOBO^HXCa ^eSHHXOKCHKaUHOH-
Haa, npoxHBOBOcnajiHxenbHaa, npoxHBOoxenHaa xepanna.
OjierMOH03Hbiffl ,iapnHinT — ocxpoe BOcnaneHHe ropxaHH, npn KOXOPOM
rnoHHoe BOcnaneHHe oxsaxbiBaex ne xonbKo cnHSHCxyio oGoJionicy ropxaHH, HO H
CBasoHHO-Mbime^HbiH annapax, HHor^a c BOBJieHeHHCM xpamefi ropxaHH (pasBHsaexca xoH^ponepHXOHjipHx). Ta5Kecxb 3a6ojieBaHHa saBHcnx ox cxenenn pacnpocxpaHCHHOCXH H Bbipa>KeHHOCXH BOcnanHxejibHoro npouecca. CKoaneHne FHOHHOro 3KCcy/;axa nponcxo^HX B Mecxax c xopoiuo Bbipa^eHHbiM noacjinsHcxbiM CJIOCM.
IlpH oxrpaHHTOBaHHH npoqecca (JjopMnpyexca a6cnecc. rtpn pasjinxoM xapaicrepe
pasBHxna xpoHHiecKoro BOcnajiHxejibHoro npouecca B ropxann
MHoro: nacxwe npocxy^Hbie saGoJiesaHHa; saxpy^HCHHe nocoBoro.
; KypeHHe; pa6oxa B nbinbHOM, cyxoM noMemeHnn; rojiocoBaa narpysKa;
xpOHHMecKOH THOHHOH HH(J)eKqHH BepxHHx flbixaxejibHbix nyxcH. Bcex HX
o6teflHHaex CXOHKHH xapaKxep H npoaonacHxenbHoe BOsaencxBHe. KaK npaBHJio,
y oanoro 6onbHoro MO>KHO BbiaBHXb cpasy HecKonbKo npn^HH, cnocoGcxByiomnx
P33BHXHK) XpOHHHCCKOrO JiapHHrHXa.
178
TeMa X. SAEOJIEBAHMfl TOPTAHM. OnYXOHH HOP-OPrAHOB
xpH ocHOBHbie (JiopMbi xpOHHHecKoro JiapHHFHxa: KaxapanbHyro,
FHnepxpo<J)HHecKyio H axpocJjHHecicyio. XPOKHHCCKHH FHnepxpo<J)HHecKHH JiapHHFHX MTOK6X SblTb OrpaHHHCHHHM H ^HfJxjjySHblM. IlaXOJIOrHHeCKHe H3M6HeHHa
HanGonee nacxo jioKannayioxca B oSnacxH FOJIOCOBHX cKJiaaoK H MOKHepnaJioBHHHOM npocxpancxBe.
Mop4>ojiorH4ecKH Bbmejiaiox:
— KaxapajibHyro (j)OpMy BocnaneHHa — cjiHsncxaa o6onoHKa yxcjimena 33
CHCX MCJIKOKJieXOHHOH HH<J)HJIbXpaHHH, CJIH3HCXHC 5KeJie3H paCUIHpCHbi;
— rrpocxyio rHnepruiasrao snHxejnw (6es axraiHH a^pa H HapymeHHa CJIOCB) —
Kepaxos, rnnepicepaxos, naxnaepMHa;
— FHnepnjiasHK) c axKHHefi snnxeJiHa (axHnna aapa, HapymcHHe CJIOHCXOCXH,
EHOMajIHa aH(})(})epeHUHpOBKH), HO C COXpaHeHHCM 3pCJIOCXH 3HHXeJlH« -
— KapUHHOMy in situ.
Ilpocxyio FHnepruiasHK) snHxeiiHa ciHxarox (JiaKyjibxaxHBHbiM
FHnepnjia3Ha c axKHHefi asjiaexca oSjinraxKbiM npe^paKOM.
XPOHMMECKMM KATAPAJIbHbIM JIAPMHrHT
BoJibHbie xcairyioxca na nepHOflHHCCKyio HJIH nocxoaHHyio ^HC(})OHHIO, nepmeHHC,flHCKOM(J)OpXB FOpHC, Kailiejlb, HHOFfla - CTeHO3HpOB3HHe. IIpH JiapHHTOCKOHHH CJlHSHCXaa HCXHHHHX FOJIOCOBblX CKJI3flOK 3aCXOHHO FHnepCMHpOBaHa, OXCHHa.
Ha HCXHHHHX H jioHCHbix rojiocoBwx cioiaAKax Moryx HaxoflHXbca cKoroieHHa rycXOH CJIH3H. IIpH 4>OHaiIHH CMblKaHHC FOJIOCOBblX CKJia^OK HCHOJIHOe. IIpH oGoCTpe-
HHH 3a6ojieBaHHa CHMnxoMbi ycHUHBaroTca. JleneHHe xpOHHiecicoro KaxapajibHoro
napHHFHxa npn o6ocxpeHHH 3a6oneBaHHa npOBO^nxca no npHHUHnaM neneHHa
ocxporo ^apHHFHxa c npHMeHCHHCM auxnGnoxHROB, BHyxpHropxaHHbix BJiHBaHHH.
B cxa/iHio peMHCCMH peKOMen/ryexca ycxpannxb (JjaKxopw, cnocoGcxByjomne nepCHCXCHUHH BocnaneHHa ropxaHH, co6nioAaxb maflamnfi FOJIOCOBOH pe>KHM. IlpoBoflaxca HHranauHH MaceJi Menxona, naHHOro aepeaa, aBKannnxa H x. a., npn neo6xoflHMocxH HasHanaioxca HMMynocxHMyjiHpyiomHe cpeacxsa.
XPOHMHECKME rMnEPflJlACTHMECKME JlAPMHrHTbl
Han6ojiee nocroanHbiM CHMHXOMOM rnnepmiacxHHecKoro JiapHHrnxa aBJiaexcaflHC(J)OHHa.Ee cxeneHb saBHcnx ox BbipaaceHHocxn H pacnpocxpaneHHOcxH
I. BocnanMTeribHbie 3a6o/ieBaHMfl ropiaHn
179
CKOIIHH nepeflHHe ABC xpern O^HOH HUH oSenx HCTHHHHX FOJIOCOBHX
oxeiHbi, cBoSoflHHH Kpafi FOJIOCOBOH CKJiaaKH no BHzry nanoMHHaex nojiHn »e:ixoGejioro HJIH ceporo uBexa, cBoGo^HO KoneSjuomHHca npn ^OHaqHH. JleneHHe —
xHpyprHHecKoe, B nocneonepauHOHHOM nepnofle HasHanaexca npoxHBOBOcnauHxejibnaa xepanna. PeuH^HBa 3a6ojieBaHHa, KaK npaBHJio, He HaSniOflaexca.
FHnepnjiacTHMecKHe ysejiKH (yaejiKH necnoD, KpiiKyiioB) — 3nHxeJiHajibHbie yxojimeHHa, Koxopbie cocxoax HS yxonujeHHoro snnxejiHa H sjiacxHiecKofi
XK3HH. HaH6onee nacxo jiOKajinsyioTca na rpaHHne nepeflHefl H cpe^Hefi xpexn
ronocoBbix CKJia^OK. JleneHHe xHpypFHMCCKoe.
KoHTaicrHbie rpaHyjieiMW — xpo4)HHecKHe assbi, no KpaaM Koxopwx o6pa3yroxca rpaHyjiauHH, nocxeneHHO noKpHsaromHeca snHxejiHCM. BosHHKaKrr KonxaKXHbie rpaHyjieMH nocjie xpaBMbi HJIH npn HpesMepnoH FOJIOCOBOH narpysKe B o6jiacxn
rojiocoBoro oxpocxna HepnajiOBHanoro xpama. HocxeneHHO noaanaexca assa H na
FOJIOCOBOM oxpocxKe npoxHBonojiTOKHOFO MepnajioBHflHOFO xpama. BoJibHbie ^cajryloxca na jjHC(})OHHio, 6ojib B ropjie. IIpH jiapHHrocKOHHH BbWBJiaexca B XHHHHHOM
Mecxe a3Ba Ha O^HOM HS rojiocoBbix oxpocxKOB, na apyroM — rpaHyjieMa.
IlaxHuepMHH — orpaHHHCHHaa (J)opMa rnnepniracxHiecKoro jiapHHrnxa.
Mop(j)OJiorHHecKH naxH^epMHa — npocxaa FHnepnjiasHa COCOHKOBOFO cjioa noKpoBHoro snHxejiHfl, B conexaHHH c BOcnajieHHCM, peaKXHBHOH npojiH(j)epaqHeH H
orpy6eHHCM no^JioKameft coe^HKHxejibHOH XKann. H3JiK>6jieHHaa jiOKajiHsauHa
naxH^epMHH — MOKnepnajioBH^Hoe npocxpaHcxso H saanaa xpexb HCXHHHHX
FOJIOCOBHX CKJiaflOK (KOHxaicxHbie naxHflepMHH). KoHxaKXHbie naxHflepMHH pacnojiaraioxca B sa^nnx ox/jejiax HCXHHHHX FOJIOCOBHX CKJiaflOK B BHfle 6jiK)flneo6pasHbix yrojimeHHH BOKpyr FOJIOCOBHX oxpocxKOB HepnanoBHjiHbix xpaineii.
JleiiKonjiaKHH — ruiocicaa HJIH cocoiKOBaa rnnepnJiasHa snHxejiHa co snaHHXCJIbHHM yBCJIKHeHHCM KOJIHHCCXBa KJICXOHHHX CJIO6B. OpH JICHKOnjiaKHH HpOHC-
xoflHX oporoBesaHHe MHorocjiOHHoro HJIOCKOFO snHxejiHa. BosBbimaiomaaca JICHKonnaKHa npe^cxaBJiaex coSoii 6yrpHCxocxb 6enoro usexa, 6es cocyancxoro pncyHKa, HC CHHMaexca npH MaHHnyjiauHH. Tjia^Kaa JieHKOnnaKHa HC BOSBbiuiaexca
naa noBepxHocxbio CJIH3HCXOH o6ojiOHKH, CHHMaexca npH MannnyjiauHax.
JICHCHHe OrpaHHHeHHHX (J)OpM XpOHHHCCKHX FHnepnJiaCXHieCKHX JiapHHFH-
XOB XHpyprHHecKoe (npo(J)HJiaKXHKa paKa ropxann!) — nposo^Hxca HOJIHOC y^aJICHHC H3MCHeHHbix xKaHCH. PeuH^HBH Ha6jnojiaioxca pe^Ko.
MOp(j)OJ10FHHeCKHX HSMCHeHHH 3nHXCJlHa.
EojiesHb FaeKa-PettHKe (oxenHaa FHnepxpo<J)Ha ronocoBbix citna/ioK) — noJTHHOBHJIHblH OXCK nepCJIHHX ^ByX XpCXCH HCXHHHblX FOJIOCOBblX CKJiaflOK. OcHOB-
Hbie naxojiorHHecKHe HSMCHCHHa npoHcxo^ax B cy6-3HHxeJiHajibHbix npocxpaHcxBax FOJIOCOBWX CKJia^oK. Cy63HHxejiHajibHoe npocxpaHCTBO naxo^Hxca MOiyry
SHHXCJIHeM H KpaCM SJiaCXHHCCKOFO KOHyCa rOHOCOBOH CKJiaflKH, BbinOJIHCHO pblX-
JIOH coeAHHHxejibHOH xKaHbio. Ero nporajKCHHocxb: ox nepeaneii KOMHCcypu flo
rojiocoBoro oxpocxica qepnajioBHAHoro xpaiya. HaH6ojibuiHM HSMenenHaM noflH Hnacnaa noBepxHOcxb rojiocoBbrx CKJia^OK. IIpH JiapHHro-
XPOHMHECKMM ATPOOMMECKMfl JIAPMHrMT
OCHOBHHC acaJio6bi 6ojibHbix — CXOHKOC HSMeneHHe rojioca, napyiueHHe flbixanna, ycHJiHBaiomeeca npH HaKOiuieHHH KopoK B npocBexe ropxaHH. IlpH jiapHHrocKonHH cjiH3Hcxaa ropxaHH HCxoHHena, cyxaa, na oxaeJibHbix ynacxKax cKanjinBaexca rycxaa cJiHsncxo-FHOHHaa MOKpoxa, sacnxaiomaa B KOPKH. JleneHHe axpo(JjHHecKoro JiapHHFHxa HanpaBJieno na noAaepxcanHe ceKpenHH coxpaHHBUiHxca
CHH3HCXHX acejies, yBJiaacHCHHe CJIHSHCXOH o6ojioHKH ropxaHH. BojibHHM HasnaHHrajMHHH 4)epM6HXOB H MaceJi (HHXXOBOFO, MCHXOJIOBOFO, SBKajinnxosoro),
180
Teivia X. SAEOJlEBAHUfl TOPTAHM. OnYXOHM JlOP-OPrAHOB
BHyxpHropxaHHbie BUHsaHHa <J>epMeHTOB, BHxaMHHOB C H B, MacjiaHbix pacxsopoB
E, MeHxonoBoro Macna. Hcnojibsyrox GnoreHHwe cxHMynaxopbi H oxxapcpe^cxBa, cxHMyjiHpyiomHe o6pasoBaHHe MOKpoxw.
II. PACCTPOMCTBA MHHEPBAL4MM TOPTAHM
II. PaccxpOMCxea HHHepBaqiiM ropraHM
181
MnonaTHHecKHe napcsw BOSHHKarox Ha 4>one BOcnajiHxenbHbix 3a6oneBaHHH, MyxauHH rojioca, nepeHanpaxceHHH ronocoBoro annapaxa. Bcxpenaroxca napeabi ronocoBbix MWIUU,, jiaxepanbHbix nepcxHeHepnajiOBimHbix Mbmiq (napnbie
napesbi), nonepenHOH HepnajioBmmoH Mbiuiiibi. IlpoaBiiaioxca napesbi yxoMJiaeMocxbio, HSMeHeHHCM x6M6pa, CHJibi rojioca. 3imojiapHHreaJibHO npn napese ro^oCOBblX Mbllim BO BpeMH (j)OHaL(HH HCXHHHblC TOJIOCOBbie CKJia^KH CMblKaiOXCa H6
Pa3HHH3iox HyBCXBHxenbHbie H aBHraxejibHbie HapymeHHa HHHepBauHH ropxaHH. HyBCXBHxejibHbie HapymeHHa HHHepB3UHH Bcxpenaioxca pe^KO, KaK npaBHJIQ, Ha 4>OHe BOcnajiHxenbHbix saSojieBaHHH, ncxepHH, xpOHHiecKOH ajiKorojibHOH
GojiesHH. HaH6oJiee Hacxo qyBCXBHxenbHbie paccxponcxBa npoaBJiaioxca ourymeHHBM KOMKa, nepmeHHCM B ropue, cyzjopoxcHbiM KauuiCM — rnnepecxcsHa ropxaHH. IIpaKXHHeCKH BCC X3KHC HaUHeHXbl HCaJiyiOXCH Ha SaxpyflHCHHe AblXaHHa,
HO o6ieKXHBHbIX HpH3HaKOB OflblHIKH HpH OCMOXpe HC BbttBJiaeXCa. FIpH HCKOXO-
pbix 3a6ojieBaHiwx HepBHoii CHCXCMM Bcxpeiaexca ranepcxesHa H anecxesna
ropxaHH, HXO npoaBjiaexca yrHexeHneM KauiJieBoro pecjmeicca, H B HCKOxopbix
cnynaax MOHCCX npHBecxH K nona/jaHHio HHOpoflHoro xena B HHHCHHC flbixaxejibHbie nyxH. JleneHne nyBCXBHxejibHbix paccxpoflcxB ropxaHH xpeSyex jieHCHHa ocHOBHoro 3a6oneBaHHX. Taicace npn rnnepecxesHH HasHanarox npoxHBOKauuieBbie
npenapaxbi, no^aBJiaromHe KamneBOH pe<})JieKC (JIHGCKCHH, xycynpeKC, KoaenaK
nap.), 3JieKxpo(j)ope3 c HOBOKaHHOM Ha o6jiacxb ropxaHH. IIpH rnnecxesHH H
anecxcsHH ropxaHH HeBponorHiecKoe neneHHe flonojironox HasHanenHeM 6HOreHHbix cxHMynaxopOB, BHxaMHHOB rpynnbi B, nposepHHa.
ame Bpany-oxopHHOJiapHHroJiory npHxoflHxca cxanKHBaxbca c napy/jBHraxeJibHOH HHHepBauHH ropxaHH. K HapyiueHHaM flBHraxeJibHOH HHHepropxaHH oxnocaxca napesbi, napajiHHH Mbiuiu ropxaHH H napHHrocnasM.
JIapHHrocna3M — cyaopora MWHIU ropxaHH, npHBO/wmaa K BHesanHOMy
CMblKaHHK) FOJIOCOBOH UJCJIH. JlapHHFOCnaSM MO5KCX npOHBJIHXbCH B BHflC KpaXKO-
BpeMCHHbix npncxynoB Bbipa5KeHHoro saxpyaHeHHa BOsayxonpOBeaeHHa
ropxaHb Bnnoxb flo ocxanoBKH awxanHfl. TaKHe npncxynw naSjiioaaioxca y
MJiafliiiero Bospacxa na 4>OHe paxnxa, araxca OHH necKOJibKO cexyHfl, nocne nero
awxaHHe BoccxanaBUHBaexca.
B peflKHx cjiynaax (y sspocjiux — na (J)OHe ncxepHH, ajiKorojibHOH
jiapHHrocnasM MO)Kex saxanyxbca na MHHyxw H Raws qacw, qxo yrpoxcaex
6oJIbHOrO. IlpH HCnpHMOH JiapHHrOCKOHHH BXOfl B ropxaHb COMKHyX, BHflHMblH
npocBex HOJIOCXH ropxaHH oxcyxcxByex. JleneHHe nanHHarox c CHJibHoro pe<J)JieKxopHoro pa3^pa>KeHHa — BHesanno o6jiHBaiox rojiosy 6onbHoro XOJIOJIHOH BOfloft, meKonyx GonbHOMy B nocy, Bbisbisaiox HaacaxneM Ha KOpeHb aswKa pBoxHHH pecjmeicc. Pe6eHKy MO»HO aaxb noHioxaxt HauiaxbipHbifi cnnpx, Bbissaxb 60JICBOH CHHflpoM mHnKOM 3a aroflHiry. IlpH npoflOJDKHxenbHOM npncxyne JiapHHrocnaaMa BHyxpHBCHHo BBOOHX npoxHBocyflopo^cHbie cpe^cxBa (penaHHyM, ay<J)HJIJIHH), npn nenpaMOH napHHrocKonHH BJiHBarox B ropxaHb pacxBOp
na. B KpaHHHX cirynaax npn6eraK)x K xpaxeocxoMHH.
nojiHOCXbK), H ronocoBaa menb HMCCX OBanbHyro 4>opMy. FIpH napese jiaxepanbHOH
Mbiminj <J)opMa TOJIOCOBOH mejin BO BpeMa (J)OHauHH poMnpn napese 3aflHCH nepcxHenepnajiOBHjiHOH Mbiumw BO speMa
rojiocoBbie CKJia^KH CMbiKaroxca, HO ocxaexca snaxb xpeyronbHHK B sa^ne
ronocoBOH menn. JlenenHe MHonaxHnecKHX napesos — FOJIOCOBOH peacHM,
HCHHC 6HocxHMynaxopOB, 4>OHoneAHHecKoe jieqenHe.
HenponaTHiecKHe napesbi noflpasaejiaiox na qenxpanbHue H nepH<J)epHHeCKHC, B 33BHCHMOCXH OX XOFO, KaKOH OXflCJI HCpBHOH CHCXCMbl CXpaflaCX.
XHHecKHe napesbi H napanHHH Moryx 6wxb O^HO- H ^BycxopOHHHMH.
napes MHLUU ropxaHH MOJKCX BOSHHKHyxb na (fione 3a6ojieBaHHa ronoBHoro Mosra
(onyxonb, KpOBOHSJinaHHe, 3Hqe4>ajiHXbi, cHpHHro6ynb6Ha H x. fl.). nepH(J>epHHeCKHC napesbi H napanHHH CBasanw c noBpeacfleHHCM BosspaxKbix nepBOB, KOXOpoe MOHCCX BOSHHKHyxb npn xpaBMe xpaxen, cxpyM3KXOMHH, cflaBJieHHH B rpyaHOH HOJIOCXH onyxonbio HJIH jiHM(})oy3naMH, npn XOKCHHCCKOM
(HH(j)eKi;HH: ITJHHH, AH^xepna, xySepKynes H x. fl., ajiKoroJibnaa,
HHXOKCHKauHfl). B pafle cnynaes npHHHHy nopaaceHHa BO3BpaxHoro nepsa ycxaHOBHXb HC yaaexca, H xoraa rosopax 06 «naHonaxHHecKOM» napese ropxaHHoro
Hepsa.
OflHocxopOHHHH napajiHH BOSBpaxHoro nepsa npoaBJiaexca npeHMymecxB6HHO HSMCHCHHeM TOUOCa, noaBJICHHCM OflblUIKH HpH <{>H3HHeCKOH
ripn jiapHHrocKOHHH HopaHccHHaa rojiocosaa CKJia^Ka Haxoanxca B
XOHHOM nono5KeHHH H coBepuieHHo Heno^BH^cHa. FIpH ^jiHxejTbHo cymecxByioIUCM napanHHe B TOJIOCOBOH cKJia^Ke nponcxoaax aereHepaxHBHbie
CBo6oflHbiH Kpafi rojiocoBOH CKJiaflKH cxanoBHXca nojiyjryHHbiM, a
HbiH xpam CMemaexca Knepe^H H BOBHyxpb. Ilpn (JjonaqHH rojiocoBaa
s^opOBOH cxopOHbi CMemaexca K nopajKeHHOH, B CBasn c HCM rojiocoBaa
npHo6pexaex KOCOC HanpasjieHHe.
IlpH flBycxopoHHCM napajiHHe rojiocoBaa menb pe3KO cyxcena, ronocoBbie
CKJiaflKH saHHMaiox cpe^HHHoe nonoaccHHe, HenoflBH>KHbi. /],BycxopoHHHH napaJIHH B03BpaXHbIX HCpBOB HpHBOflHX K 3Ha/HHXejlbHOMy HapyUICHHIO flblXaHHa. Ilo-
cKOJibKy HenponaTHHecKHe napajiHHH pasBHsaroxca nocxeneHHo, 6ojibHOH ycnesaex «npHBbiKHyxb» K KHcuopo^HOMy ronoflaHHio. O^HaKO na 4>OHe (^HSHHCCKOH
narpysKH, ocxpbix BOcnajiHxenbHbix 3a6ojieBaHHH CXCHOS ropxann MOKCX Gwcxpo
napacxaxb. B 3XOM cjrynae nposoflnxca xpaxeocxoMHa.
182
Tewa X. SABO/lEBAHUfl TOPTAHH. OnYXO/lM JlOP-OPrAHOB
ill. onyxojiM nop-oprAHOB
OnyxojiH BepxHHX flbixaxeJibHbix nyreft H yxa no/ipasflejiaioxca na
cxBCHHbie H floGpOKawcxBeHHbie. Bbmejiaiox xaoce ycJiOBHo
onyxonn, oGjiaflaiouiHe nepxaMH flo6poKaHecxBeHHbix H sjiOKanecxBeHHbix onyXOJICH. OKOHijaxejibHbiH flHarnoa onyxojiH BOSMOMCCH TOJibKo nocne ee rHCTOnoBCpH(J)HKaHHH.
onyxo/iM ropraHu
IlanHJiJiOMa — HaH6onee ^acxo BCxpeHawmasca onyxonb, pasBHBaiomaaca
MS nnocKoro H nepexoflHoro anHxejina. B saBHCHMOcxH ox KOJinnecxBa coeflHHHxejibHOH xKaHH B cxpoMe onyxojiH paajinnaiox Manoie H xBep^bie nanmuiOMbi.
Cpe^H 6onbHbix nanmuiOMaxosoM npeo6jiajjaiox flexH B Bospacxe flo 10-H nex, xoXH H y Bapocjibix nanrauioMa ropxaHH — Hepe^Koe saSojieBanHe. Y flerefi HanGojiee aKXHBHbift pocx, peu.nn.wsu nanmuioM Ha6jnoaaiOTca c panHero sospacxa ^o
5-H nex. K noJiOBOMy cospesaHHio pocx nanmuioM aaMejuiaexca, HUH OHH Moryx
HCHesHyxb BOBce. Boneiox name ManbHHKH. KnHHHHecKoe xeneHHC nanHiuiOMaxoaa
ropxaHH y flereH H B3pocnwx pasnoe. Y aexen pasBHBaioxca MHO»cecxBeHHbie nanHJinoMbi, Koxopbie saHHMarox 6ojibiiiyio nacxb ronocoBbix cioiaflOK, cyacHBaiox
npocBex rojiOBOH menn, saxpy^Hfliox abixaHne, peqHaHBHpyiox. Y Bspocuwx nanHJMOMa ropxaHH — e^HHHHHoe, MCflJieHHO pacxymee o6pa3OBaHHe. Ilpo«BJiHexCH nanniiJiOMa ropxaHH y sspocjibix nocxoxHHOH AHC(J)OHHeH. OxpHnnocxb FOJIOca nocxeneHHO napacxaex, noaBJiHioxca nepHoaw a<J)OHHH, Hapacxaex cxenos ropnapHHrocKonHH naHHJUiOMbi rojiocoBbix cKjia^oK posoBoro HUH KpacHoro UBexa, y /texeH no <j)opMe HanoMHHarox usexHyio Kanycxy, nexyuiHHbiH rpe6ent. JleneHHe — 3naonapHHreajibHoe yaajienHe onyxojiH. /],onojiHHxejibHO naSHanarox npoxHBOonyxojieBbiii npenapax — npocnH^HH HJIH npoxHBOBHpycHbie
npenapaxw — pea(J>epOH, HHxepcJ)epoH.
reManr HOMa — cocyflHcxaa onyxonb, Hcxo^amaa name scero H3 nepnajionaflropxaHHbix HJIH BecxnGynapHbix CKJiaaoK. FeMaHrHOMbi Moryx 6bixb ^H<J)4>y3HWMH H HHKancyjiHpOBaHHbiMH. AHrHo<J)H6poMbi Bcxpenaioxcfl peflKO, JioicaJiH3yK)Tca na HCXHHHbix ronocoBbix CKJiaflKax. KnHHHKa onyxojiH saBHCHX ox ee
. FeManrHOMbi BecxnGyjiapnoro ox^ejia ropxaHH npoaBJMioxca
HHopo^noro xejia B ropxaHH, noKamnHBaHHCM. HocxeneHHO noaBjiaioxca 6onH, npHMecb KPOBH B MOKpoxe, H3MeneHHe ronoca. Onyxonb na HCTHHHOH rojiocoBoii CKJiaflKe npoasjiflexca npexyje Bcero H3MeneHHeM ronoca,
no Mepe pocxa onyxojiH yxyamaexca flbixaHHe.
K3K oflHH H3 nepBbix CHMHxoMOB xapaKxepHO pflx onyxojiH,
HS noflCKJia/ioHHoro oxaena ropxaHH. JlenenHe reManrHOM CBasano c BOSMOHCHOcxbio pasBHxna HHXpaonepauHOHHoro KpOBoxeneHHa. HHKancyjiHpOBaHHbie re-
I. Onyxonn DOP-opraHOB
183
noflneacax 3HflonapHHreajibHOMy yflanenHK). /jHcJxJtyanbie onyxonn
nonBeprarox MHoroKpaxnoH KpHo^ecxpyKHKH.
flpyrne floSpoKaiecxBenHbie onyxonn (jinnoMbi, MHOMH, XOH^POMH, HCBpnHOMbi, aaeHOMbi H flp.) Bcxpenaioxca pe^KO.
3/ioKaMecTBeHHbie onyxonM ropraHn
Pan ropraim — caMaa nacxo BCxpenaeMas sjiOKaiecxBeHHaa onyxonb JIOPopraHOB. 65-70% 6ojibHbix co sjioKanecxBeHKbiMH onyxojraMH JIOP-opranoB
cxpa^aiOT paKOM ropxaHH. 3a6ojieBaiox paKOM ropxaHH B OCHOBHOM jiHu,a cxapuie
40iiex, cpe^H HHX npCBajinpyiox MyacHHHbi. Pe5Ke paK ropxaHH BCipenaexca y
6oJiee MOJio^bix jnoaen, cpe^H HHX npesanHpyiox HceniuHHti.
IlpHHaxa e^HHaa MeacflyHapoflHaa KJiaccH^HKauna paKOBbix onyxoneH, KOxopaa ocHOBana Ha jiOKajinsauHH H pacnpocxpaHCHHOcxH onyxoiiH, HanHHHH perHonapHbix H ox^ajieHHbix MexacxasoB. Coraacno BXOH KnaccH(J)HKaHHH, paKOByio onyxonb o6o3Haqaiox xpeMa CHMBOJiaMH: T — nepBHHHaa onyxojib, N —
perHOHapnbie Mexacxasw, M — oxaajieHHbie Mexacxaabi. IIo jioKajinsauHH paaiiHnaiox paK BepxHero, cpeflnero H HHacnero ox^ejioB ropxaHH.
KnaccH^HKauHH pana ropraiiH no CHCTCMC TNM:
TO — nepBHHHaa onyxojib HC onpeaenaexca;
TI — onyxonb orpaHHiena O^HHM OX^CJIOM OZIHOH anaxoMHHecKOH o6nacxH
, C HOpMaJIbHOH HOflBHHCHOCXblO;
onyxonb orpaHHHCHa ropxanbio, pacnpocxpanaexca na OAHH HJIH HCcocejjHHx oxflcJioB B npeflejiax oflHOH anaxoMKHecKOH o6jiacxH HJIH na
aaaxoMHHecKyio o6jiacxb, c HopMajibHOH HJIH orpaHHHeHHOH noaBH3KHOCXbK>;
T3 — onyxojib orpaHHHCHa ropxaHbio c (J>HKcauHeH H/HJIH jjpyrnMH npH3HaKaMH ray6oKOH HHtj)HJibxpauHH;
T4 — onyxojib pacnpocxpanaexca sa npeflejiwropxaHH;
T, — onpeaejiHXb pacnpocxpaneHHOcxb nepBHHHOH onyxojiH HCBOSMOHCHO;
NO — pernoHapHbie jiHM<j)axHHecKHe ysjibi He najibHHpyioxcji;
NI — najibnnpyioxca cMemaeMbie jiHM(})axHiiecKHe ysjibi na cxopone nopa— najibnnpyioxca CMemaeMbie JiHM(J)axHHecKHe ysjibi na cxopone nopaHJIH c o6enx cxopon;
NS — najibnHpyioxca HecMemaeMbie jiHM<})axHHecKHe ysjiw;
MO — oxflajieHHbie Mexacxasbi ne onpe^ejiaioxca;
MI — oxflajieHHbie Mexacxasbi onpe^ejiaioxca;
M, — oxflajieHHbie Mexacxasbi onpe^ejiHXb HCBOSMTOKHO.
scero nopa»caexca BepxHHH ox^eji, pe»e — cpeflHHH, eme peace —
npocxpancxBO. PaK Bepxnero H cpeanero ox/jejia ropxaHH o6na3K3o<J)HXHbiM pocxoM c BbipaaccHHOH HanpaBJiCHHocxbio pocxa Bnepea H
184
TeMa X. SAEOJlEBAHHfl TOPTAHH. OnYXO/lM JlOP-OPrAHOB
KBepxy. Hs onyxojieH Bepxnero oxAena HaH6onee nacxo Bcxpeqaexca paK
ropxaHHHKa. CioiaflKH npeAABepna peAKO aBJiaroxca nepBHiHoK
paKa, xoxa B npouecc BOBJieKaioxca nacxo. PaK cpeAHero oxAena HaH6onee qacxo
HCXOAHX HS nepeAHHX AByx xpexeft HCXHHHOH FOJIOCOBOH cioiaAKH, nopajKaa ee
BepXHIOK) HOBCpXHOCXb H CBO6OAHbIH KpaH. OnyxOJIb pacxex 3K3O(j)HXHO BAOJlb
CKJiaAKH K nepeAHefi KOMHccype, 3axeM nepexoAHx Ha npoxHBononroKHyio POJIOcoByro CKJiaAKy. Jlfia onyxojien HHacnero oxAena ropxaHH xapaKxepen 3HAO<J>HxHHH pocx, HanpaBJieHHe pocxa — BHHS. Mexacxasnpyex paK ropxaHH npeHMyuie-
I. Onyxo/iM flOP-opraHOB
185
CHMnxoMaxHHecKoe neneHHe H xHMHOxepamw noKasaHbi npH HanHHHH
JICHHHX MexacxasoB, Koxopoe yKassieaex na reHepanHsauHio onyxoneBoro npouecca.
Onyxonn Hoca n oKOJioHocoebix nasyx
flOBPOKAHECTBEHHblE
IlanHJiJiOMa. Ho rncxojiorHHecKOH cxpyKxype pasuHHawx
CXBCHHO HO JIHM(J>aXHHeCKHM HyXSM.
(3K3O(})HXHyK)), nepCXOAHO-KJieXOHHyiO (UHJlHHApO-KHeXOHHyio) H HHBepXHpO-
KnHHHKa paKa ropxaHH saBHCHX ox noKanHsauHH onyxoJIH. OnyxonH Bepxnero oxaejia ropxaHH A-raxeJibno npoxeKaiox 6cccHMnxoxMHO. BosMoxcHbi aaneHHa
H (nepmeHHe, omyuieHHe HHOPOAHOFO xejia B rnoxKe), Kaiuenb, nonepnpn npncMe MCHAKOH HHIUH, napecxesHH. Ilo3Hce noaBJiaexca GOJICSHCHHocxb npn raoxanHH. Bojib B ropue nocxeneHHO ycnnHBaexca. B MOKpoxe HOHBjiaexcH npniviecb KpoBH. OnyxoJIH cpe^Hero oxACJia MaHH^ecxnpyiox HaH6onee
6bicxpo. B paHHHe cpoKH noaBJiaexca AHC<}>OHHH, Koxopaa 6bicxpo nporpeccHpyex. Bo3HHKaex saxpyAHeHHe ^bixanHfl. Onyxonn cpeanero ox/iena HS-basBnaioxca
BaHHyio nanHJinoMW. rpH6oBH^Haa nannjuiOMa HCXO^HX HS KOJKHOFO anHAepMHca H jioKajiH3ycxca B npeAflBepHH Hoca. IlepexoAHO-KJiexoHHwe H HHBepxnpoeaHHbie nanHJUioMbi ncxo^ax HS pecnnpaxopHoro snnxejiHa HOJIOCXH noca. IIpH
ocMOxpe rjiaAKaa noBepXHOCXb axnx onyxojieH HanoMHHaex HOUHH. HHBepxnpoBaHHaa H nepexoAHO-KJiexoHHaa nannjuiOMbi o6jiaAaiox AecxpynpyiomHM pocXOM, CKHOHHbi K Ma^HrHHsaqHH, Koxopaa Hacxynaex y 4-5 % 6ojibHbix. Jleqenne
nanHJinoM — xHpyprHHecKoe.
FeMaHrHOMa COCXOHX HS KpoBenocHbix cocyAOB pasnoro xnna. B o6.nacxH
Hoca name BbiaBnaioxca reManrHOMbi KannjinapHoro xnna, xoxa xaicace Bcxpenaioxca KaBepHOSHbie H sexBHCXbie onyxoJIH. Flo Mepe pocxa onyxonH noaBJiaioxca
peuHjiHBHpyiomHe HocoBbie KpOBOxeneHHa, saxpyAHeHHe AwxaHHa H T. a. JieneHHC orpaHHieHHbix reManrHOM — XHpyprHHecKoe. HnorAa npH 6onbiuoH pacnpocxpaHeHHOCXH onyxonH npnGeraiox K nepeBasKe napy^KHOH COHHOH apxepnn.
/^HfJxJiysHbie reManrHOMbi noflneacax KPHOBOSACHCXBHK).
Ocreowa — onyxonb, ncxo/iamaa H3 KOCXHOH XK3HH. Jlflu ocxeoM xapaKiepen Me/jneHHbiH pocx. HanSonee nacxo Bcxpenaroxca ocxeoMbi no6Hbix, peuiexqaxbix nasyx. OflnaKO ocxeoMa MO^cex pasBHXbca HS jno6oH nacxn nepena. B
peflKO, B CBS3H C HCM KpOBOXapaHbC HC pa3BHBaCXCa. IlpH paSBHXHH OnyXOJIH
HHacnero ox^ejia ropxaHH noaBJiaexca CHanana npHCxynoo6pa3Hoe, KpaxKOBpeMeHHoe, a saxeM nocxoHHHoe napyuieHHe AbixaHHa. TOJIOC HSMenaexca nocxeneHHO npn BOBJieneHHH B npoiiecc rojiocoBbix CKna#OK.
paKa ropxann nocxoanHO coBepiueHCXByexca, Ba»HeHiiiHMH
ocxaioxca nenpaMaa jiapHHrocKonna H rncxcjiorHHecKoe HccjieAOBaHHC 6nonxaxa.
OCHOBHHMH MexoaaMH jieieHHa aBJiaroxca XHpyprHnecKHH, JiyqeBOH H HX
KOM6HHai;HH. Hpn onpeAeneHHH oSteMa onepauHH opHeHXHpyroxca Ha opranoc6eperaioiuHe onepaxHBHbie BMemaxeubcXBa (pasjiHHHbie Bapnanxbi peseKUHH
ropxaHH).
JleneHHe SOULHHX c MexacxaaaMH B perHonapHbix JiHMtfmxHHecKHX ysnax —
HanSonee cjioxcnaa sa/jana. IloaBJieHHe MexacxasoB sHannxenbHO yxyauiaex npoFH03. Mexacxasbi — HanSojiee qacxaa npHinna CMepxn 6onbHbix paKOM ropxaHH.
Mexacxasbi paKa B JiHM(J)axHHecKHX ysnax ManoHyBCXBHxenbHbi K o6jiyHeHHro.
RJIX neneHHa paxa ropxaHH c MexacxasHpOBaHHCM B jiHM<j)axHHecKHe ysiiw men
npHMenaexca onepaxHBHoe jieHenne.
OnepamiH Kpanjin. IIoKasaHHe — HajiHHHe orpaHHHeHHO no^BH5KHbix MCxacxasoB B JiHM^oysnax men. yaajieHHio nofljieacax: KJiexnaxKa GOKOBOFO
men, ray6oKHe apeMHbie JiHM(J)axHHecKHe ysjibi, rpyflHHo-KJiioH
naa Mtimua, BHyxpeHHaa apeMHaa Bena, noflHenrocxHbie JiHMc[)axHHecKHe y3Jiw,
noflHcmocxHaa cjiiOHHaa wenesa.
Ov rjinpno-(})acuna/ii,iian jiiiM(})afleH3KTOMMH npoBoanxca npn HajiHHHH
noABH>KHbix MexacxasoB. yjianaexca xonbKo KnexqaxKa H jiHM<j)oy3Jibi GOKOBOFO
IdlHHHHeCKOM XeHCHHH OCXCOM BblAenaiOX ABa nepHOfla - JiaXCHXHblH H aBHblH.
/],jiHxejibHocxb jiaxeHTHoro cymeciBOBaHHa onyxo^H MOHCCX Aocxnraxb AecaxKOB
jiex. KnHHHKa saBHcnx ox jiOKajiroauHH H CKOpocxn pocxa onyxoJIH. B asHbifl nepHOA Ha6nKwaexca nocreneHHoe, neyioioHHoe napacxaHHe cHMnxoMaxHKH. ITpoasjiaexca onyxonb HapymeHHCM 4>yHKL(HH noca, AC(})opMai;HeH nHLia, CMemeHHCM
rjiasHoro a6jioKa. JleneHHe OCXCOM — XHpyprHHecKoe.
flpyrne rncxojiorHHecKH Ao6pOKanecxBeHHbie onyxoJIH (MHOMBI, JIHHOMU,
4)H6pOMbi, HCHporeHHbie onyxonn) B oSnacxn Hoca Bcxpenaioxca KpaHne pe^KO.
CHMnxoMaxHHecKoe jieneHHe H xHMHOxepanna noKasanbi npn HannnHH oxaaJICHHWX MexacxasoB, yKasbiBaioinHX na renepajiHsaiiHio onyxoneBoro npoiiecca.
3JlOKAMECTBEHHblE OnYXOJlM HOCA M RPMAATOMMblX FIASYX
Flo nacxoxe BcxpeqaeMOCTH cpeAH onyxojieH BepxHHX AwxaxejibHbix nyxen
SJiOKanecxBeHHbie onyxoJIH noca H ero npHAaxoiHbix nasyx ycxynaiox xoubKO onyXOJWM ropxaHH. Boneiox B OCHOBHOM JIIOAH cxapme 50 Jiex. HanSojiee nacxo 3JioKaHecxBCHHbie onyxojin HcxoAax HS peiuexnaxoro Jia6npHHxa H BepxHeneJiRDCXHOH
nasyxH. Hs sJiOKaHecxseHHbix onyxojieH name Apyrnx Bcxpenaexca paK. B o6nacxH
186
III. Onyxo/iM JIOP-opraHOB
187
TeMa X. SAEOJlEBAHUfl TOPTAHH. OnYXO/ll/l JlOP-OPrAHOB
Hapy>KHoro noca pasBHBaexca 6a3aJibHOKJiexoiiHMH paK (GaaanHOMa), B nonocxH
Hoca — ruiocKOKJiexoHHbiH oporoseBaioiuHH paK HJIH ajjeHOKapuHHOMa. KnHHHKa
sa6ojieBaHHa saBHcnx ox jiOKajinsauHH, pacnpocxpaneHHocxH onyxoneBoro npouecca, a xanace ox Mop^ojiorHnecKOH cxpyKxypw HosooOpasoBaHHa. HeKOxopoe
BpeMa onyxonb pasBHBaexca 6eccHMnxoMiio, HJIH ee npoaBJienHa fleiiHKaxHbi H Mano 6ecnoKoax 6oJibHoro. OnyxojieBbiH npouecc nepeaKO MacKHpyexca HOA xponnnecKoe BOcnaneHHc OKOJTOHOCOBWX nasyx, cxoMaxojiorHiecKHe 3a6oneBaHHa. Y
HCKOXOpblX SoJIbHblX B KJIHHHH6CKOH KapXHHC AOMHHHpyiOX HOCOBblC KpOBOXCHe-
HHa. /tnarHocxHKa onyxoneM HOJIOCXH Hoca H npHJiaxoHHbix nasyx ^oBonbHO xpyana, nocKOJibKy xapaKxepHbix CHMHXOMOB o^enb MOJIO. Heo6xoflHMO o6pamaxb
BHHMaHHe na nocxoaHHoe napacxaHne oflHocxopoHHeft cHMnxoivtaxHKH, HecMoxpa
na npoBO,KHMoe JieneHHe. JIcHeHHe 6o:ibHwx sjiOKanecxBeHHbiMH onyxoiWMH Hoca
H npnaaxoHHbix nasyx npOBO^xx xHpyprHHecKHM MBXOAOM, nyneBOH H XHMHOXC. Hcnojibsyioxca xaioKe KOM6HHaijHH yKasannbix
Onyxonn rnoxKM
Us ^o6pOKaHecxBCHHbix onyxoneS HOCOFJIOXKH HanSojiee nacxo Bcxpenaroxca nanmuiOMa H lOBeHHJibHaa 3HrHO(})H6poMa.
IlanHJijiOMbi HocornoxKH noKajiHsyroxca na aaflHeii nosepxHocxH Mancoro
He6a, name na (})OHe nanHiuioMaxosa poxoraoxKH. Onyxont HMCBX xapaKxepntiH
BHfl: ceposaxoro usexa, na mnpoKOM ocHOBanHH, c sepHHCxofi noBepXHOcxbio.
JleneHHe XHpyprHHCCKoe.
K)Beiinjii,iiaH (roiioiuecKaH) anrno(|)n6poMa — onyxonb cBo^a HOCOFJIOXKH, Bcxpenaexca npaKXHHecKH xojibKo y ManbHHKOB noapocxKOBoro Bospacxa.
Onyxonb o6naaaex MCCXHUM aecxpyHpywHiHM POCXOM, B csasn c ICM oxnocHxca
K ycnoBHO sJiOKanecxBeHHbiM onyxonsM. THCxouorHHecKH onyxonb COCXOHX HS
coe^HKHxejibHOH XKaHH H cocy^OB pasjiHHHOH cxeneHH speJiocxH, pacnojio>KeHHbix xaoxHHHO, B XOM HHCJic no noBepXHOCXH onyxoJIH. Onyxonb MaHH(J>ecxHpyex
flocxaxoHHo 6wcxpo. /^jia KJIHHHKH xapaKxepno nporpeccHBHOe yxy^meHHC HOCOBOPO zibixaHHfl, peuH/jHBHpyiomHe nocoBbie KpOBOxe'ieHHa. Ho Mepe pocxa
onyxoJIH nacxoxa H HHxencHBHOcxb KpoBoxeneHHH yBCJiHHHBaioxca. V 6ojibHbix
pasBHBaexca xpOHHiecKaa nocxreMopparHiecKaa aaeMHa. Elpn npopacxaHHH
onyxoiiH B npH^axoHHbie nasyxH noca noHBJiaexca rojioBHaa 6onb, BOcnajiHxejibHwe HSMeneHHa. Onyxojib Moacex BbiSBaxb /xecxpyKUHio ocnoBaHHx qepena H
npOHHKHyxb B ero nojiocxt. Flpn saaneH pHHOCKonHH onyxojlb CHHrouiHa, HMCCX
6yrpncxyK) nosepXHOcxb. Flpn najibueBOM nccneaoBanHH HOCOFJIOXKH onyxojit
ruioxHa, na naiibue ocxaexca Kposb. Hqie^Ko aHrao4)H6pOMa MacKHpyerca noa aaeHOHflbl HJIH XOaHajIbHblH nOJIHII. B ^HarHOCXHRC tOBCHHJlbHOH aHTHO^HGpOMbl HaH-
Gojibiuyio ueHHOcxb npe^cxasjiaex racxojiorHHecKoe HCCJieflosaHHe 6Honxaxa H
KOMntioxepHaa xoMorpaiJ)Ha. JleneHHe lOHomecKOH aHmo4)H6pOMbi XHpyprHHecKoe.
OpOBeaeHHe onepauHH Bceraa conpaaceno c onacnon ana ^OISHH 6ojitHoro HmpaonepaixHOHHOH KpOBonoxepefi. C itejibio yMCHbiiieHHa KpoeonoxepH no
BPCMCHH HcnojibsOBanacb npe/XBapHxenbHaa nepesasKa napyacHOH COHHOH
apxepHH na cooxBexcxByiomeH onyxojin
cxopone. Iloj;o6Hoe BMeuiaxejn>CTBO He
Bcer^a npeaoxspamano MaccHBHoe
KpoBoxeneHHe, B CBasH c HCM xpe6oBaJiacb nepesasKa o6enx Hapyaoibix COHHbK apXCpHH, HXO HpHBOflHJIO K pCSKOH
HixieMHH, HCKposaM B 6acceHHax ^anHWX apxepHH, B nacxHOCTH — B o6jiacXH JiHua. B noc-Jie/jnee BpeMa .ana
npe/joxBpameHHa HHXpaonepauHOHHOPuc. 24. PeHTreHKOHTpacTHaa 3H/iOBacKyro KpOBOxeneHHa ncnojibsyexca npe/iOKKJIIO3H5I BCTBH HapyXHOH COHHOH
BapHxejibHaa 3M6ojiH3aiiHa cocyAOB
aprepHH, nHTatomefi 3HrHO(})H6poMy
onyxojiH (pnc. 24). Haiye acero onyxojib y^anaiox HS uinpoKoro napywHoro ^ocxyna no Mypy.
3jioKaiecTBeHHbie onyxojiH HOCOIJIO i KM cocxasjiaiox OKOJIO 40 % BCCX onyxojiefi rjioTKH, Bcxpenaioxca name y Myac^HH. 3nHxejmajn>m.ie onyxojiH name Bcxpeiaioxca y JIHU. cxapiiie 40 Jiex, coeflHHHTejibHOXKaHHbie — y JIHU MOJIO/JOFO sospacxa H
. Hanobjiee nacxo BCTpenaexca paK. PaK HOCOFJIOXKH oxjinnaexca BHCOKOH sjioKa, 6bicxpbiM pocxoM, paspyuieHHCM OKpyMcaioumx TKaHefi. Onyxojlb,
Hcxoaamaa HS SOKOBOH CXBHKH B o6jiacxH nioxOHHoro KapMana, BbiSbiBaex flHC^yHKUHK) cjryxoBOH xpy6bi H CHH»ceHHe cjryxa. B STOM cjiynae nepeaKO onyxojn. #HaraocxHpyex span cypaojior. C pocxoM onyxoim noaBJiaerca saxpyaneHHe HOCOBOTO abixaHHa. PaK HOCorjioxKH pacxex HH<J)HJibxpaxHBHO, 6wcxpo HstasBJiaexca, vm npHBOOTX K
HOaBJICHHIO KpOBaHHCXbDC BbWejICHHH H3 HOC3 H HOCOrJIOXKH. HapyUICHHe BeHXHJiaUHH
nasyx Hoca o6ycjioBJinBaex pasBHxne xpoHHHecKoro CHHynxa. XnpypJieHCHHe onyxojiefi HOCOFJIOXKH Kpanne aaxpyjiHHTeJibHO, B CBa3H c HCM
6oJibuioe pacnpocxpaHeHHe nojiynHJia jxyneBaa xepanna.
Hs ;io6pOKaMecrBeniibix onyxojiefi POTOFJIOTKH HanSojiee nacxo Bcxpenaioxca nanHJUiOMbi H reMaHrHOMbi. IlanHJiJiOMW — eflHHHHHbie HJIH MHoacecxBeHHbie oxflejibHbie 3HHxejiHajibHbie o6pasoBaHHa, pasMep Koxopbix pe/iKo npeBbiiuaex 1 CM. Pacnojiaraioxca nannjuiOMbi na HeGnbix ^y»Kax, He6Hbix
GOKOBWX noBepxHocxax aswKa. TeMaHrnoMbi oGbinno jiOKannsyioxca na
HJIH MareoM neSe, xoxa MOHCHO Bcxpexnxb H flpyryro JiOKajiHsauHio. BojibHbie c
onyxojiaMH FJIOXKH xcajiyroxca Ha nepuieHne, nyBcxso
xejia B rjioxKe, noKauuiHBaHHe. JleneHHe nannjuioM XHpyprHHecKoe,
jieneHHa reManrHOM npHMenaexca Kpno/iecxpyKUHa, npn BOSMOJKHOCXH —
Hs 3JiOKaHecTBCHHbix onyxojieii pororJiOTKH name apyrnx BcxpenaioTca
pax (y JIHU cxapme 40 Jiex) H capKOMa (y JIHU ao 40 Jier H Aexeii).
188
Teiwia X. SAEOJlEBAHMfl TOPTAHM. OnyXOJlM JlOP-OPrAHOB
Hbie onyxojiH poxornoxKH oxjinnaioxca 6bicxpbiM HH<})HJibxpaxHBHbiM pocxoM H MCxacxasHpoBaHHeM, cicnoHHbi K H3"ba3BJieHHK> (CM. pHC. 17 npmiOHceHHa). y 6ojibHHX co sjioKanecxBeHHHMH onyxoJiaMH poxorjioxKH nepBoft noaBJiaexca Hcano6a na
omymeHHe HHOpoanoro xejia B FJIOXKC. KOTCKOM(J)Opxy6bicxpo npHCoezmHaexca
6onb, JioKajiHsoBaHHaa B MCCXC omymeHHa HHOpoflHoro xena. FIpH pacna^e onyxoJIH y 6onbHoro noaBJiaexca rHHJiocxHbiH sanax H3O pxa, npninecb KPOBH B CJHOHC.
HHor^a HS onyxojiH BOSHHKaiox npo<}>y3HHe KpOBOxeneHHa. Ilo Mepe BOBJieneHHa B
npouecc Mancoro ne6a, CXCHOK FJIOTKH noaBJiaexca oxKpbixaa raycaBocxb. Ha cxopone nopa*eHHa Gbicxpo noaBJiaioxca perHOHapnbie Mexacxasbi. JlenenHe 3JiOKanecxBennbix onyxojieft poxoraoxKH XHpyprHHecKoe H JiyneBoe.
B ropraHorjioTKe HS aoSpOKanecTBeHHbix onyxojieft xaioKe HanGojiee nacxo Bcxpenaroxca nannjuioMbi H reMaHraoMbi. IIOMHMO CHMHXOMOB, xapaKxepHblx
fljia jioKajiroauHH aaHHbix onyxojieii B poxorjioxKe, y 6oJibHbix noaBJiaexca AHC(Jtarna. JlenenHe XHpyprHnecKoe.
Ha sJiOKanecTBeHHbix onyxojiefi ropxaHorjiOTKH H3H6oJiee nacxo Bcxpenaexca paK. H3Jiio6jieHHaa JioKajiHsanHa — nepnajioHaflropxaHnaa CKJiaARa. RJW
paica ropxanoraoxKH xapanxepeH 3K3O(j)HXHbiH pocx, Sbicxpoe npopacxanne B
ropxanb. BojibiuHHCXBO 6ojibHbix na paHHefi cxa^HH passHXHa onyxojiH »cajiyioxca na omymeHHe HHOpoanoro xejia B raoxKe. IIpH saaeftcxBOBaHHH ropxaHH noasjiaroxca acajioSbi na oxpmuiocxb rojioca, Kamejib, saxpyAHCHHe flbixaHHa. IlpH
pacna/ie onyxojiH noaBJiaexca rHHJiocxHbiH aanax HSO pxa, npHMecb KpoBH B
MOKpoxe. JleneHHe onyxojieft ropxanorjioxKH xnpyprHHecKoe H JiyneBoe.
I. OnyxonM JlOP-opraHOB
189
KaK no noBepxHOcxH, xaK H Brjiy6b yiiiHofl paKOBHHbi. PasBHBaexca
PHX, noaBJiaroxca OOJIH. IljiocKOKJiexoHHbiH paK pacxex 6bicxpee
XOHHOFO, HMeexca cicrioHHOCxb K MexacxaanpoBaHHio. SjiOKanecxBeHHbie onyxojiH
Hapy?KHoro cjiyxosoro npoxoAa AHarnocTHpoBaxb SHanHxenbHo xpyflnee. OHH
jjjiHxejibHoe BpeMa ocxaioxca HesaMeneHHbiMH, noKa HC o6xypHpyiox npocsex
cjiyxoBoro npoxo^a, HXO npHBOAHx K CHH^ceHHio cjiyxa. HepeflKo sjioKaiecxBCHHbie onyxojiH napyiKHoro cjiyxoBoro npoxo^a npoaBJiaroxca syaoM B yxe, FHHJIOCXHblMH BbWejieHHSMH H3 yxa
C npHMCCbK) KpOBH. OnyXOJIH HHJKHCH CX6HKH
cjiyxoBoro npoxo^a nepes canxopHHHeBbi IIICJIH npopacxarox B OKOJioyuiHyio
cjnoHHyK) acejiesy. Hs KOCXHOH lacxn Hapy»Horo cjiyxosoro npoxojia onyxoJIH
6bicxpo pacnpocxpanaioxca B 6apa6aHHyio nojiocxb.
3jiOKaHecxBCHHbie onyxojiH cpeflnero yxa B 90-95 % cjxynaeB pasBHBaroxca
na <J)OHe xpOHHHecKoro rHOHHoro cpeflHero oxnxa c npojiH(])epauHeH. HanGojiee
nacxo Bcxpenaexca pan. CapKOMa Bcxpenaexca pe^KO, npeHMymecxBeHHO y fleXCH. OepBbie npoaBJieHHa onyxojiH Mano HCM oxjiHHaioxca ox o6ocxpenHa xpoHHHecKoro oxHxa. flajibHeHiuHH pocx onyxojiH Bbisbmaex napes JinueBoro Hepea,
BecxnGyjiapHbie paccxponcxBa, CXOHKHH GOJICBOH CHH^POM. JleneHHe 6ojibnwx co
SJiOKaiecxBeHHbiMH onyxojraMH yxa XHpyprHHecKoe H JiyneBoe.
Bonpocbi Rna Mxoroaoro KOHrpojin 3H3HMM no reue X
1. KaKMe >Kano6bi 6ojibHoro yKa>Kyr Ha Bocnantixe/ibHoe nopa)KeHMe
ropraHM?
2. B H6M KnMHMHeCKHe OTJ1HMMH paSBMXMH MCXMHHOrO M JlTOKHOrO KpynOB?
Onyxonu yxa
flo6poKanecxBeHHbie onyxojiH HapyxcHoro yxa — nanHJUiOMbi, ocxeoMbi,
<})H6pOMbi, reManrHOMbi. /jHaraocxHica HX He Bbisbmaex saxpyflHeHHH, jieneHHe
XHpyprHHecKoe. B cpe/iHCM yxe H3flo6pOKaHCCXBeHHbixonyxoJieH Han6ojiee
nacxo Bcrpeiaioxca xeMO^eiciOMbi H reManrHOMbi. XeMOJieKXOMa — onyxojib,
Hcxo^amaa HS raoMycHbix xejieu,, pacnoJiararoinHxca no xoay HepBHbix BOJIOKOH
H cocyaoB B CHHSHCXOH o6ojiOHKe 6apa6aHHOH nojiocxH. Flo Mepe pocxa XCMOfleKXOMbi y 6ojibHbix noaBJiaexca nyjibCHpyroiiniH uiyM B yxe, CHH^cenHe cjiyxa.
IIocTeneHHO paspymaa 6apa6aHHyio nepenoHKy, onyxojib noaBJiaerca B napy»cHOM cjiyxoBOM npoxo^e B smie apKO Kpacnoro nojiHna. KnHHHKa pocxa reManTHOMbi cpe^Hero yxa npaKXHHCCKH xaKaa ace, OJJHEKO jxna reMaHraoM xapaKxepHH KpOBOxeneHHH HS yxa.
Us 3JioKaHecTBCHHbix onyxojieii Hapyacnoro yxa naH6ojiee nacxo acxperuiocKOKJiexoHHWH H 6a3ajibHOKJiexoHHbiH paK yuiHOH paKOBHHH. BapaK (GasaiiHOMa) noaBJiaexca B BHJie naxntiuiKa HJIH «npbimnKa» na yuiHOH paKOBHHe, Koxopoe MCAJICHHO pacxex, HO HC npHHHHaex 6ecnoKoficxBa. Cnycxa 5-lOMecaueB onyxojib nstasBjiaexca. HerjrySoKaa asBOHKa
noKpbixa KopOHKOH. C noaBJieHHCM assbi 3HanHxejibHO ycKOpaexca pocx onyxojiH
3. KaKMe dpaicropbi npeflpacno/iaraiox K paaBMxmo xpOHMMecKoro napnHrnxa?
4. B HGM OXJIMMMG xeneHMJi nannnnoMaxo3a ropxaHM flexeii H eapocJlblX?
5. KaKMe aaGojiesaHMH ropxaHM OTHOcnr K o6nnraTHOMy npeapaKy?
6. B new oxnMMMfl MaHMCpecxauMM onyxoneii eepxHero, cpeAHero v\o OTflenoe ro
7. Onyxonn Kararo otAena ropxaHM Mexacxasnpyiox HaM6o/iee 6bicxpo?
8. KaKMe npMsnaKM noMoryx flucJjdpepeHMMpoBaTb (OBennnbHyio aHrnodpM6pOMy HOComoxKM ox runepxpodpMM FJIOXOMHOM MMHflajiMHbi?
9. Flo K3KHM npn3HaKaw MOWHO 3anofl03pnxb snoKaMecxseHHyio onyxonb nojiocxM noca, POTOPJIOTKM, ropxaHornoxKM, cpeflnero yxa?
I. TpaBMbi JIOP-opraHOB
191
Heox^ojKHOM noMomn ripn 3a6ojieBaHnax JIOP-opraHOB ao Hacxoamero BPCMCHH ocxaercs O^HHM H3 HaH6onee BEXCHBIX H OTBexcTBeHHtix pasflCJIOB COBpCMCHHOH OTOpHHOJiapHHFOJlOrHH. B OTOpHHOJiapHHrOJIOrHH K COCTOXHH5IM, Tpe6yK)lU,HM OKasaHIW HeOTJlO)KHOH CneUHaJIH3HpOBaHHOH nOMOIIiH, OTHO-
eMa XI.
HEOTJlO)KHblE COCTOflHMfl
B OTOPMHOJlAPMHrOJlOrMM
caxcx xpaBMbi JIOP-opraHOB, KpoBoxeneHHa, HHOpoflHbie xeiia JIOP-opraHOB,
cxeHOSbi ropxaHH, ocxpaa ceHCOHeBpajibHaa xyroyxocxt, oxo- H pHHorenHwe
BHyxpHHepenHtie OCJIOHCHCHHS. B npneMHtie HOKOH JIOP-oxfleneHHH cxauHOHapoB r. HoBOCHGnpCKa, paSoxaromHX no OKaaanHio HCOXJIO»CHOH noMomn, eaceoGpamaioxca 6onee 1 O-H TMCSH MCJIOBCK.
I. TPABMbl JlOP-OPrAHOB
Bpewm
— 180 MMH/T.
L|ejib 33HHTHH.
no>KHoii
Heox-
1. Pa3o6parb oco6eHHocTM
npn xpasMax JlOP-opraHOB.
2. Hsy-iMTb npnewbi n3BneM6HHfl unopoflMbix Ten
JIOP-opraHOB.
3. Pa3o6paib npunnHbi HOCOBOPO KpoBOTeneHMn.
MsyMMXb MBTOflbl OCXaHOBKM HOCOBOTO KpOBOXeHGHMfl.
4. HsyHMTb KJlHHMHeCKI/ie OC066HHOCTM CT6H03a fOp-
T3HM Ha pasHbix cxaflMflx, MeroAbi jieneHMH cieHOsa rop5. HsyMMTb npuMMHbi n npuHqunbi neMeHMfl ocrpoM
rnyxoTbi.
OcHameHMe. OcBernTenbHbie npuSopbi: MCTOHHMK
CBera, no6Hbi(i pec|)neKTOp. fleMOHCTpaqnoHHbiki n/iarepnan: nnaKarbi, cnaiiflbi.
Ha6op MHCTpyweHTOB. HocoBbie sepKana, ujnaieHM, HOCornoTOHHbie sepKana, aoHflbi HaBMBHbie, nnHqeibi
HOCOBbie.
Pa6onee MBCTO. MHCTpyMeHTanbHbiii CTOJIMK, HaCTonbHan nawna, cnnproBKa, flsa cryna.
Mecro nposefleHMfi saHnriiH. VHe6Ha^ KOMHara.
PeKOMeHflyewan nMTeparypa:
1. Condamoe M. B. HeKt^Mn no oTopMHonapMHronornki. — M.: Meflni4MHa, 1990.
2. LUeepbiauH B. B. PyKOBOACTso no fleicKOM oropnHonapnHro/iornn. — M.: MeflnqnHa, 1985.
JIOP-opraHOB Bcxpenaexca npH xpaBMax JiHqeBoro nepena, yxa
H oSjiacxH ineH. Tonorpa4)HHCCKaa 6^Hsocxb KpynHbix MarHcxpanbHbix cocy^OB H
ronoBHoro Mosra o6ycjiOBjiHBaiox BO MHOFHX cnyHaax BOSMOJKHOCXB BOSHHKHOBCHIW xpaBMaxHHecKoro moKa. Bpan, OKasbmaiomHH Me^HmiHCKyio noMomb, 30:15KCH HCMe/uieHHo npHiwTb cooxBercxByiomHe Mepw: o6e36ojiHBaHHe, corpeBaHHc,
BHyxpHBCHHoe BBefleHHe KpOBesaMCKHxejieH. IIpH HapymeHHH qejiocxHocxH KO»HblX nOKpOBOB nOKaSaHO BBCflCHHe npOXHBOCXOJl6H«HHOH CblBOpOXKH.
Cpe^H xpaBM JIHUCBOFO CKCJiexa naHGonee nacxo Bcxpenaioxca MexaHHieCKHC noBpexyieHHa noca. Pasjinnarox yuiH6 noca, paHenna MarKHx xKaneft Hoca,
nepenoM HOCOBHX KOCXCH H nospejiyieHHa OKOJIOHOCOBHX nasyx.
Hapy>KHoro Hoca — aaicpbixoe noBpoKfleHHe, np'HHHHOH Koxoporo
y^ap neSojibuiOH cunw xynbiM npe^MexoM. CHMnxoMbi: npHnyxnocxb H
6ojie3HCHHOCXb MarKHX XKaneH Hoca, He6ojibiuoe KpOBOxeneHHe H3 Hoca, npH nepeflHCH PHHOCKOOHH oSHapyxcHBaexca OXCK cnHsncxoii oSojiOHKH noca, HHOr^a — crycxKH KpOBH B HOCOBWX xoaax. Ha R-rpaMMax KOCXCH Hoca npH3H3KH
nepejiOMa oxcyrcxByiox. Jlenenue yiunGa Hoca — noKOH, npHMCHCHHe xojio^a
MCCXHO B nepsbie CJTKH nocne xpaBMbi. Kaic ocjio^cneHHe yuin6a Hoca MOJKCX
BO3HHKHyxb reMaxoMa HOCOBOH neperopoaKH.
PaiieiinH iiapyyKiioro Hoca nepejiKO XOJU,KO BHCiiiHe Ka>Kyxca noBepxnocxHbiMH, a BfleHCXBHxenbHOCXHnpOHHKaiox ray6oKo; B rjrySHHe paHbi Moacex naxoflHXbca
HHOpOflHoe xejio. ECJIH noflospeHHe na HanHHHe HHOpo^Horo xena B03HHKaex npn
paccnpoce 6onbHoro HJIH npn ocMoxpe pain,!, neo6xoflHMO npoi}3BecTH R-rpa4)Hio
KOCXCH Hoca H OKOJiOHOCOBbK nasyx B ziByx npoeKUHax. CcajjHHbi, uapanHHbi o6paGaxbiBaiox 5 % HacxoHKOH fioaa. PaHbi Manoix XKaneH noca npOMbmaiox nepeKHCbro
Bo^opofla, Kpaa noBepxHocxHbix pan nocue o6pa6oxKH cimpxoM c6jiH>KaK)x nojiocK3MH neHKOiuiacxbipfl, raySoKHC panbi, nocjie onnmeHHa ox rpasH, y^aneHHa HHOpOAHbEX XCJI H pa3MO35KCHHbIX, HCKpOXHSHpOBaHHblX XKaHCH, 3aiIIHBaiOX. rtepBH^HblH
IHOB na HHue naKJiajibmaiox B xeneHHe cyxoK nocne xpaBMbi, npH oxcyxcxBHH BocnaaBJieHHH flonycxHMO 6onee nosflHee (no 48 nacoB) saiiiHBaHHe panti.
192
TeMa XI. HEOTJIOXHblE COCTOflHMfl B OTOPHHOJlAPMHronOn/IM
FIpH nOJIHOM OXpblBC KptUia HJIH KOHHHKa HOCE BO3MOHCHO npHJKHBJICHHe OXXOprHy-
TBIX TKaneH, CCJIH c MOMenxa xpaBMti npoimio ne 6ojiee cyroK. OxopsaHHbie xpamn
KptuibCB Hoca HC npouiHBaioT, a conocxaBjwiox c noMomtio arpaBMaxHHecKHx mejiKOBbix IIIBOB Ha KO>Ky H KenyroBbix — Ha cjiHSHCiyio oSojioHKy.
11. l~loBpe>KfleHMfl oKonoHocoBbix naayx
193
Flpn ycxanoBJieHHH jiHKBOpeH GojibHbie noane>Kax cpOHHon rocnnxajiHsauHH.
HaH6onee nacxtiMH ocjio>KHeHHaMH xpasM noca aBJwroxca reMaxoMa H a6cHOCOBOH neperopojiKH, jieneHHe Koxopbix npOBOflHxca B ycjiOBHax JlOP-cxaUHOHapa.
Heo6xOflHMO IIOMHHTb O TOM, HTO B CBH3H C XOpOIUHM KpOBOCHa6)KeHHeM
jiHiia npH paHCHHax aoca, jiHija cymecxByiox «HO>KHHn,bi» MOKjry cxenenbio xa5K6CTH xpaBMM H BHCUiHHM BHflOM 6onbHoro, KoxoptiH HHorjja nyraex flaace MCflHKOB. Ejiaroflapa xopomeMy KpoBOCHa6>KeHHK> Maranx xKaHeii Jinua npn ITXO
pan HCCCKaioxca Jiniiib aBHO ne>KH3He-cnoco6Hbie ynacxKH xKaneH. YKymeHHbie
paHbi Hoca no/iJie>Kax OXO, a oxKyuieHHbie <J>parMeHXbi noca Moryx 6bixb npnuiHTbi, xoxa no saKonaM xHpyprHH yKymeHHbie panw HBJISIOXCX nepBMHHO HH(J)HUHpOBaHHbiMH H He no^Jie^ax yiiiHBaHHio.
IlepejioMbi KOCTCH Hoca. PasuHHaiox oxxpuxbie H saKpbixwe rrepenoMH, co
CMeiUeHHCM H 6C3 CMCmeHHfl KOCXHblX OS^OMKOB, C KOCMeXHHCCKOH H 6e3 KOCMCXHHCCKOH AC(})OpMaL(HH HapyXHOFO HOCa.
: 6onH, nocoBoe KpOBOxeneHHe, ppfyopManwi Hapy5KHoro Hoca, Jio6ojie3HCHHOcxb, omymeHHe KpenHxaqHH OXJIOMKOB, naxojiorHHecKax no«npH naubnauHH KOCXCH noca. EipH no^ospeHHH na nepenoM Heo6xoflHMa
R-rpaiJ)HH KOCXCH noca B ^syx npoeKumix. B saBHCHMOcxH ox MexanHSMa xpaBMbi
Moryx Ha6jiioaaxbCH nepenoMbi Kocxeft noca c SOKOBWM CMemeHHCM OXJIOMKOB H
BflaBjieHHbie nepenoMbi KOCXCH Hoca. flfisi penosHUHH npn ncpenoMax KOCXCH Hoca
co CMemeHHCM nporoBOflflx anecxesHK) CMasbiBaHHCM CJIHSHCXOH o6ojioHKH 2-4 %
pacxBOpoM flHKaHHa c 0,1 % pacxsopOM a^peHajiHHa 3a 20-30 MHHJT %o peno3HUHH. BHyxpHMbmieHHO BBOOTX 2 MJI 50 % pacxBopa aHajibraHa HJIH 1 -2 % pacxsopa npoMeflOJia. EecnoKOHHbiM 6ojibHbiM, aexaM H nojjpocxKaM HHor/ja Heo6xoijHM
KpaxKOBpeMeHHtiH napKos. ^CM paHbiiie npoHSBOOTxca penosHiina Hoca, XBM jierne
ona ocymecxBJiaexca. KpanHHH cpOK penosnuHH — 4 neaejiH nocjie xpaBMbi. ITpH
neperopoflKH noca uejiecoo6pa3Ha ee ranepKoppeKUHa. Ilocjie penonpOH3BOJiHT ncpejjHioio xaMnoHafly Hoca HJIH cnapyxH na GOKOBHC CXCHKH
Hoca yioiaflbiBarox MapJieBo-KaruioAMeByio (J)HKCHpyiomyio nosasicy. IloBpeHCfleHHe
KO>KH (npn oxKpwxbix nepcjioMax KOCXCH Hoca co CMemeiiHCM) sauiHBaiox nocne
penosHUHH H BbinonHCHHa xaMnoHaflbi Hoca. IlpoxHBonoKasaHHaMH Jijia neMe^JICHHOH penosHiiHH nepeJiOMa KOCXCH Hoca aBJiaioxca: coipaceHHe rojiOBHoro MO3ra, cHrnanbHwe (x. e. BHesanHbie, o6HJibHbie H 6bicxpo npeKpamatomneca) HOCOBbie KpOBoxeHCHHa, xpaBMaxH^ecKHH LUCK, nasanbHaa jiHKBOpea.
HcxeqeHHe cnHHHOMOsroBofi »HJIKOCXH H3 Hoca MOKCX 6bixb oGnapyaceHo:
a) no najiHHHio flByxKOHxypnoro naxna na noaasKe HJIH 6ejibe;
6) npo6ofi c HocoBbiM njiaxKOM — CMOHCHHWH jiHRsopoM HOCOBOH nuaxoK ne
KOpo6nxca, x. K. B jiHKBOpe Hex Myunna, coflepJKauieroca B HOCOBOH CJIHSH;
B) npn 6noxHMHHecKOM HccjieaoBaHMH oxaejiacMoro H3 noca onpe^ejiaexca
HanHMHe caxapa, Koxoporo Hex B ceposntix HJIH cjinsncxbix BbiaejienHax HS noca
npH pHHHxax.
II. nOBPE)KflEHMfl OKOJlOHOCOBblX HA3YX
TpaBMbi npnaaxoHHbix nasyx Hoca pe^KO Gbisaiox HSOJinpoBannbiMH, o6binHO OHH conexaioxca c noBpe5KA6HHaMH noca, rjiasa, qejuocxen, CKyjiosoH KOCTH,
coxpaceHHCM, ymnSoM MO3ra, a HHor/ja paspbiBOM MOSTOBOH oBojioiKH H BHVTreMaxoMOH. PaajiHnaiox oxKpbixbie (npn paneHHax KOXCH H MancM^
H saKpbixwe (6es noBpe>KJieHHa KO>KH), npOHHKaromHe H ne npOHHKaioB nojiocxb nepena xpaBMbi OKOJionocoBbix nasyx. Oco6o onacnbiMH aBJiaioxca ornecxpejitHbie paneHHa npHflaxonnbix naayx Hoca, nocKOJibKy npn OKaaannH
HCOXJIO>KHOH noMomH xpe6yiox coBMCcxnoro ynacxna oxopHHonapHHrojiora,
cxoMaxonora, OKyjincxa, HenpoxHpypra H penxrenojiora.
Us H30JinpoBaHHbix noBpeacfleHHH OKOJioHocoBbix nasyx name scero Bcrpcqaioxca xpaBMbi peuiexqaxoro jiaGnpHnxa, nepe^HCH CXCHKH jio6HOH nasyxn,
npoaBJiaroiiiHeca OXCKOM BCK H KOHCH n6a, noflKO»HOH 3M(j)H3eMOH, HHorjja —
CHFHajIbHblMH HOCOBblMH KpOBOTBHeHHaMH.
Jleneme. Bee 6ojitHbie c xpaBMaMH npHflaxonnbix nasyx noca AOJIJKHH 6bixt
rocnHxajiHSHpOBaHbi. IIpH noBpe>KfleHHH CTCHOK nasyx 6es CMemeHHa OXJIOMKCB.
c HesHaiHxejibHbiM HX cMemeHHCM — JieieHHe KoncepBaxHEHoe (nocxejibHbiii
pe>KHM, npoxHBOBOcnajiHxejibHaa xepanna, saKanbisaHHe cocyflocyxcnBaiomHX
cpeflcxB B HocoBfaie xo^bi, npHMeHenne aHXHrncxaMHHHbix npenapaxos). Heo6XO^HMO sanpexHXb 6ojibHOMy CMOpxaxbca fsjin npeAynpe5K/ieHHa HH<J)HiJ,HpOBaOKOJIOHOCOBHX nasyx H MarKHX xKanefi Jinua. HoaBJieHHe npH3H3KOB naB nasyxe xpe6yex ee HCMCAneHHoro BCKpbixna H PCBHSHH. XnpyprHHt CKaa peBH3Ha jioSnoH nasyxn a6cojiioxHO noKasana npn MHoroocKOJibiaxbix ee
nepejioMax c noBpe>KfleHHeM sa^HeH CXCHKH H npronaKaMH nopajKenna nepe^HeH
nepenHOH SIMKH, a xaK»ce npn npoHHKaiomHx paneHHax.
TpaeMbi yxa. TpaBMW ymnoH paKOBHHbi c noBpoKflCHHCM KO>KH noaJie5Kax
nepBHHHOH xnpyprHHecKOH o6pa6oxKe no npHHqnnaM xHpyprHnecKOH o6pa6oxKH pan jiHHa. npHHunnw flHarnocxHKH H JieneHna oxoreMaxoMbi yKasanw B pa^^ene «3a6o;ieBaHHa yxa». IIpH paapbisax 6apa6aHHOH nepenoHKH npn 6apoxpasMB (yaap jiaflOHbio no yxy, BHesannoe HSMCHCHHe BHeuinero axMOC(})epHoro jjaBJICHHa) Heo6xOflHMO 33KpbIXb HapyHCHblH CJiyXOBOH npOXOfl CXCpHJIbHblM BaXHbIM
xaMnoHOM, HasnaHHXb 6onbHOMy anxnGnoxHRH ^jia npeaynpeayieHHa socnariH
xejibHoro npouecca B 6apa6aHHOH HOJIOCXH, cocyflocyncHBaiomHe Kanjin B cooxBexcxByromyK) nojiOBHHy Hoca ofla yjiyniueHHa flpeHa>KHOH <})yHKnHH cjiyxoBOH
xpy6w. BoJibHOMy sanpemeno CMOpKaxtca, npOTHBonoKasano npoMbisaHHe yxa.
194
Teiwa XI. HEOTJlOKHblE COCTOflHHfl B OTOPHHOJlAPMHrOJlOrHH
noMomb OKaswBaexca 6o;ibHbiM c MexaHHHecKHM
6apa6aHHoK nepenoHKH (BasanbHOH cnHueH, BCTKOH flepesa H x. #.); Hy>KHO
HMexb B BHfly, HXO onacHOCXb HH(}>eKUHH cpeflHero yxa s^ecb 6ojibiue.
TpaeMbi opraiioB UICH — onacnbie #Jia HCHSHH 6ojibnoro cocxoaHHH BBHjy
B03MOWHOCXH paSBHXHfl XpaBMaXHHeCKOFO HJIH rHnOBOJieMHHeCKOFO IUOK3, OCX-
poro cxenosa ropxanH, MaccHBHoro KpoBoxeneHHH, napyuieHHH BHyxpHMOsroBOro KpoBoo6pameHHS. B oKasaHHH cneuHajiHSHpoBaHHOH noMoiuH npH xpaBMax
men Hepe^KO oflHOBpeMCHHo ynacxByiox BpaiH HecKOJibKHX cneu,HajibHocTeH:
xpaBMaxojior, peaHHMaxojior, oxopHHOJiapHHrojior. IloBpe>KfleHHfl JIOP-opraHOB
npn xpasMC UICH HaOjiiOflaroxca npH c#aBjieHHH wen, CHJibHOM yaape no nepeflHCH, 60KOBHM noBepxHOcxaM IIIBH xynwM npeflMexoM, npn KOJioxo-pesanbix paHCHHax nepe^nefi H SoKOBbix noBepXHOcxefi men, ornecxpejibHbix paneHHax.
IlpH cflaBjieHHH, yflape o6:iacxH men cjie^yex HCKJiioHHXb nepejiOM xpamefi
ropxaHH, o6pa30B3HHe reMaxoMbi nojiocxn ropxaHH.
TeMaxoMa HOJIOCXH ropxaHH npoaB^aexca saTpyflHeHHCM flbixaHHa, ocnnjiocxbro rojioca, 6ojibio B ropjie. Ilpn nenpaMOH JiapHHrocKonnH B BecxH6yjwpHOM
oxaene ropxaHH onpeflejiaerca CHHioiiiHoe MaraoxKaHHoe o6pa3OBaHHe na OAHOH
H3 nonoBHH ropxaHH, npHKpwBaiomee rojiocosyio meJib. no^BH>KHOcxb ropxaHH
c nopaaceHHOH cxoponw orpaHHHCHa. BojibHOH c reMaxoMOH ropxann HyHgiaerca
BO BpaneGHOM HaSnroACHKH. ripoBO^HTca npoxHBOoxeHHaa, reMocxaxHHecKaa xepanna. ITpn napacxanHH cxenosa ropxaHH npoBOflHxca xpaxeocxoMHa. FeiviaxoMa
ropxaHH HepeaKO cowexaexca c nepejiOMOM xpameH ropxann. CHMHXOMH nepeJiOMa xpamefl ropxaHH sasHcax ox CXCHCHH CMemeHHa OXJIOMKOB xpamen, napymcHHa uejiocxHocxH CJIHSHCXOH oGojioiKH ropraHH. Ilpn HenoBpeayieHHOM KOHCHOM noKpoBe men Ha nepejiOM xpamefi ropxaHH yxaacex 3M(J)H3eMa o6nacxH ropxaHH. B ocxajibHOM CHMnxoMbi xe ace, HXO H npn reMaxoMe ropxaHH. EojibHOH c
nepejiOMOM xpamefi ropxaHH no;pie3KHx 3KcxpeHHOH rocnHxannsauHH. IlpH pa3BHXHH cxeHosa ropxaHH III-IV cxaflHH noKasaHO HanoaceHHe xpaxeocxoMbi. HaSHaHaexca aHXH63KxepHanbHaa, npoxHBOOxeHHaa, reMocxaxniecKaa xepsnna.
III. Ocxpaa HekipoceHCOpHan ryroyxocxb
195
ocxporo ncHKOsa, reMopparnnecKHX zinaxe3OB, uienHoro ocxeoxoaaposa c cnaapoMOM HO3BOHOHHOH apxepHH, BCFeXO-COCyflHCXOH flHCXOHHH, HC(J)pHXa, BpOafACHHO-
ro CH(J)HirHca, BOSMOKHM ocxpwe HapymeHHa KpoBoo6pameHHa B naOnpHnxe y coBepmeHHO saopOBbix JIHU B pesyubxaxe crpecca HJIH nocne ajiKoronHsauHH);
— ocxpaa axyxpaBMa.
B MexaHHSMc Koxjieo-BecxH6ynapHbix HapymenHH npH HapyuieHnax KPOBOo6pameHHa BHyxpeHHero yxa HMCIOX seaqenHe ranoKCHa ero peuenxopoB BCJICACXBHC ne/iocxaxoHHoro npHxoxa apxepnanbHOH KPOBH, noBbiiueHHe ^aBJieHHa B
jiaGnpHHxe BCJIC^CXBHC peaKXHBHoro oxexa, rH6eJib BOHOCKOBWX KJICXOK KopxHeBa oprana, peuenxopoB noJiyKpyKHbix KanajioB H MemoHKOB npeflABepna.
CnMnxoMaxHKa paccxpoficxB KpOBOoSpameHHa BO BuyxpeHHCM yxe saBHcnx or
xapaKxepa naxonorHnecKoro npouecca (cnasM, xpOMSos, 3M6onHa) B 6acceHHe naGHPHHXHOH apxepHH H ox KannSpa cocy^a. OSbiHHO HaSjiioaaexca coHexanne npn3H3KOB HapymeHHa cnyxa H BecxH6ynHpHOH (})yHKUHH. BojibHbie 5Kanyioxcfl na BHC33HHO noaBHBUiHHca uiyM B yxe BbicoKoro xona (SBOH, CBHCX), CHH3KeiiHe cnyxa
(BlUIOXb JIf) nOJIHOH O^HOCXOpOHHCH FJiyxOXbl), rOJIOBOKpyHCCHHe, XOUIHOXy, pBOXy.
npH oGcne^oBaHHH o6Hapy>KHB3K)xcH nop3>KeHHa 3ByKOBOcnpHHHMaK>mero annapaxa, o6bi4HO oxcyxcxBHe cnyxa Ha nopaaccHHOH cxopone, Sp ropHSOHxanbHOpoxaxopHbiH HHCxanw B saopOByro cxopony, flByxcxopoHnee npoMaxHBaHHe npn BHnonHeHHH KOOp^HHaiiHOHHbix npo6, OXKJIOHCHHS! HJIH naaeHHa B cxopony nopaaceHHoro yxa npn CXOSHHH B nose PoM6epra H npn xoflb6e c saKpwxbiMH raasaMH.
c npH3H3KaMH ocxporo HapymeHHa KpoBOo6p3iueHHa B Ji36npHHxc
B CPOHHOH KOHcyjibxaijHH OKyjincxs, xepanesxs, HCBponaxojiora. -?eo6mHH anaiiHs KPOBH, MO^H, nccjieaoBaHHe CBepxbiBaromeH H npoiHBOCBepXbIB3K)IHeH CHCXCM KpOBH. Heo6xOflHMO nOMHHXb, HXO Jia6HpHHXHaa ap-
xepna HBJiaexca KOH^eBOH BexBbio cncxeMbi apxepHH Bepxe6po6a3HJiapHoro 6acceHHa, nosxoMy /inarHos ocxporo HapymeHHa KpoBoo6pameHHa B Jia6HpHHxe ne
HCKJiioHsex o^HOBpeMeHHO HJIH nocjieflOB3xejibHo p33BHB3K>meroca ocxporo paccxpOHCXBS KpoBOo6pameHHa B sa^Hcii nepennoH aMKe.
OCXpblH HH^CKUHOHHWH KOXJieOBeCXH6yjiapHbIH HCBpHX CJiyXOBblX HCpBOB
III. OCTPAfl HEMPOCEHCOPHAfl TYrOYXOCTb
Ocxpaa HeiipoceHcopHaa xyroyxocxb, BHesannaa rayxoxa OXHOCHXCX K HCOXCOCXOaHH^IM, npHpaBHHBaCMblM K OCXpOMy 5KHBOXy, HH(J)apKXy MHOKapfla, X. K. npH OXCyXCXBHH HCMeflUCHHOH HHXCHCHBHOH XCpaHHH CHH^CCHHe CJIyxa
npnoSpexaex CXOHKHH, Heo6paxHMWH xaparrep.
B renese ocxpon HCHpoceHcopHOH xyroyxocxH jieacax:
— OCXpblH HH^CKIXHOHHblH KOXJieO-BeCXH6yjlflpHbIH H6BpHX;
— ocxpoe oxpaBUCHHe OXOXOKCHHCCKHMH anxnGnoxHRaMH;
— ocxpwe HapymeHHa KpoBoo6pameHHa BO BHyxpeHHCM yxe (cna3M, 3M6o, xpoM6o3 Jia6HpHHXHOH apxepHH H ee BCXBCH) Ha 4>one TB, axepocioieposa,
name Bcero pa3BHB3exca na 4>OHe rpnnna, uepe6pocnHHanbHoro MCHHHnra, napoTHxa, CKapJiaxHHbi, 6proiiiHoro XH(J>a, HH(J)eKaHOHHoro renaxnxa.
Ocxpoe oxpaBJieHHe oxoxoKcnqecKHMH anxH6HOXHKaMH HanGoJiee nacxo
BosHHKaex npn HcnojibSosaHKH aMHHorjiHKOSHflOB, npe^pacnojiaraiomHMH (J>aKxopaMH aBJiaroxca aexcKHH Bospacx, nopa*eHne HOICK HJIH neieHH, Bbipa>KeHHHH axepocKjiepos, 6epeMeHHOcxb, amieprHHecKHe cocxoaHHa.
JleneHHC ocxpofi HefipoceHcopHOH xyroyxocxH nanpaMyro sasHcnx OT SXHOJIOFHH 3a6ojieBaHHa. Tepannio HeHpocencopHOH xyroyxocxH MOJKHO npe/jcxaBHXb
cjieayiomHMH oSpasoM:
1) 3XHOXpOHHoe JieneHHe (oxMena 3HXH6HoxHKOB, aesHnxoKCHKauna,
H npoxHBOBOcnajiHXCJibHaa xepanna);
2) aHXHrHcxaMHHHbie npenapaxw;
196
TeMa XI. HEOTJlOKHblE COCTOflHUfl B OTOPHHOJlAPHHrOJlOrUM
3) cpeflCTsa, ynynmaiomHe <J>oc(J>opHbiH, yrjieBOjiHbiH H GCJIKOBHH o6MCH —
ATO, KOKap6oKCHjia3a, u,epe6poJiH3HH;
4) cnasMOJiHXHKH;
5) flHypeXHKH, HO HC OTOTOKCHHHblC;
6) BHxaMHHH BI, B6;
7) nposepHH;
8) cpeflCXBa, yjiynuiaiomHe MHKpOHHpKyjiauHio;
9) ceflaxHBHbie npenapaxw.
Ocrpan aicycTHHecKaH Tpaeivia BOSHmcaex npH BO3fleftcxBHH na opran cnyxa
CHJibHoro KpaxKOBpeMeHHoro sayica (niyM peaKXHBHbK jjBHraxejieH, sayic BbiptiBaiomerocfl ro-nofl 3CMJIH npHpoAHoro rasa npn SypeHHH CKBaaoiH, CBHCXOK napOBOsa, BHcxpeji, BsptiBbi na 6J1H3KOM paccToaHHH, nocemeHHc KOHuepxoB poK-rpynn). HpesMepHOC pasflpaaceHHe BOJiocicoBbix KJICXOK peuenxopoB KOpraeBa oprana npHBOflHT K pesKHM 6HOXHMHHCCKHM CflBHTaM B XKaHflX BHyTpCHHerO yxa, COCyjJHCXblM HapyUieHHHM,
oxeny ero nepenoHHaibix o6pa3OBaHHH, noBbmieHino flaBJiemiH nepH- H 3RUOJiHM4)bi.
KpOMe Toro, npH AeroHaujHH (Bbicxpen, Bspbis Ha 6nn3KOM paccxoaHHH) HMCCX MCCXO
BjnMHHe MexaHHHecKOH xpaBMbi cxpyioyp qjcflHero H BHyrpeHHero yxa B03flyuiHOH
BOJfflOH, B pesynbxaxe nero pasBHBaexca xyroyxocn. CMeuiaHHoro xnna. OflHaxo ne
cymecreyex napannejiraMa Msxjsy xajKecxbio nopaaceniM cpemero H BHyrpeHHero
yxa. HepeflKO o6napy»CHBaexca nojmax rayxoxa npn HHxaKXHOH 6apa6aHHOH nepenonKe. CHMirroMbi: cpasy nocne xpaBMbi BosHHKaex tiiyM, SBOH, 6ojn. B yiiiax, nepefljco roJiOBOKpyaceHHe, BbipaxcenHaa xyroyxocxb CMemaHHoro xnna. Mo»ex Ha6juoflaxbca
cnoHxaHHbm mm no3HiiHOHHbiH ropHSOHxanbHo-poxaxopHbiH HHcrarM, HapyuieHHe
BecxH6ynocnHHajn>Hbix peaKi]HH no na6HpnmHOMy xmiy. JleneHHe npHHUHimanbHO
He oxjraHaexca ox TepanHH ocxpofl HeHpoceHcopHOH xyroyxociH cocyAHCxoro renesa.
IV. MHOPOflHblE TEJ1A YXA
HHOpoAHbix xcji jioKajiH3yeTCH B HapyacHOM cnyxoBOM npoxoae,
H jiHiiib H3peAKa OHH OKasuBaioxca B nojiocxH cpe^Hero yxa. HnopoaHbiM XCJIOM
Moacex 6bixb jno6oH npeaMex, pasMepw Koxoporo OOSBOJIHIOX eMy npOHHKHyrt xy^a, B XOM HHCJIC H 5KHBOC HaCCKOMOC. Cpe^H HHOpOflHblX TCJ1 C^CflyeT pa3JIHH3Xb
CBo6oflHO jiexcamne H BKJiHHCHHbie, a xaicace Ha6yxaroiiiHe sepna ropoxa, KyKypysw
H x. n., OKasbiBaiomiie BCC ycanHBaromeeca flasjieHHe na CXCHKH cjiyxoaoro npoxo^a. npH nariHHHH HHOpoanbix xen Moryx oxMenaxbca sanoxcenHocxb yxa, uryM,
omymeHHe aaBJieHHa, GOJIH, HHoraa Bbi^ejieHHe KPOBH, npH HX JiOKajinsauHH B noJIOCXH cpe^Hero yxa — npHsnaKH pasapaaceHiw HJIH yrHereHHH jia6npHHxa, napes
HJIH napanHM jiHuesoro Hepsa. J\narno3 ycxanaBJiHBaiox na ocHOBaHHH anaMHeCXHHCCKHX .naHHbix, Hcajio6 SojibHoro H pesyjibxaxoB OXOCKOHHH.
JICHBHUe. HCMCAJICHHO Heo6xOflHMO yflailHXb HHOpOflHOC X6JIO, KOXOpOC BbI3bI-
Baex CHJibHyio 6onb jin6o yxce npHBeno K pasBHXHio BOcnajmxejibHoro npouecca B
V. HHOpoflHbie rena nojiocTM Hoca M npMflaroMHbix naayx Hoca
197
yxe BO Hs6e>KaHHe eme 6ojiee onacHbix nocjieacxBHH. OcHOBHbiM CHOCOOOM
HHOpojHbix TBJI HS napyacHoro cjiyxosoro npoxo^a HBJiaexca npOMbmaHHe,
HC3(J)(J)eKXHBHOCXH HpOMblBaHIM npHMCHHKIX HHCXpyMCHTajIbHOe yflajlCHHC. B
CHMOCTH ox oco6eHHOCTeH Ka3Kjj,oro KOHKpexHoro cjiynasf jma yflaneHHa HHOpo,o,Hbix xeji Hcnoubsyiox yuiHbie KproHKH, cneuHanbHbie yuiHbie mnnubi, mnnuiji HS
Ha6opa, npeAHasHaneHHoro Jira BbinojiHCHHa MHKpoonepau,HH na yxe. IlpH
BOcnaneHHa Hapy>KHoro CJIyxoBoro npoxoaa HHor^a npHxoflHXca ox:io>KHXb
HHC HHOpo^Horo xena na neKoxopoe Bpcivw, AJW xoro Hxo6bi c noMoujbio aHXHSnoxHKOxepanHH ,ao6HXbcs perpeccHposaHHa BOcnanHxeJibHoro npouecca.
B cjiynae, BCJIH BKJiHHCHHoe HnopoflHoe xejio HC y^aexca yflajiHXb nepes
napyxcHbiK cjiyxoBOH npoxoji, HJIH CCJIH HHOpojinoe XCJIG naxoflnxca B HOJIOCXH
cpeflHero yxa, cjiejjyex Hcnojibsosaxb XHpyprHHecKHH napy^HbiH HO/JXOJJ,. IlosaflH yiiiHOH paKOBHHH npOBO/WT paapes 40 KOCXH AJIHHHOH 3-4 CM, oxcnaHBaiox n
pacceKaiox cjiyxoBOH npoxofl, HXO cos/iaex yaoSHbin flocxyn K HHOpo^HOMy xejiy.
O^naKO HHorjia npnxo/iHxca AonoJinnxejibHO pacuinpaxb Kocxnyio nacxb cnyxoBoro npoxo^a, y6pas ero sa^Hioio cxeHKy.
Mxo6bl H3§e»CaXb BKJIHHHBaHHa HJIH npOXajIKHBaHHa HHOpOflHblX TCJI B
nee yxo, Hy»HO noMHHXb flBa npaBHJia:
1) OKpyrjibie, c<}>epHHecKHe HHOpo^Hbie xejia yjjajiaioxca HJIH
HJIH KptOHKOM;
2) HHOpo^Hbie xejia, y Koxopbix npeo6jiaflaiox jiHHeHHbie napaMexpu, yjjajiaroxca nHHqexoM.
>KHBbix HacexoMbix yflajiarox H3 HapyjKHoro CJIyxoBoro npoxozja npoMbiBaHHCM nocjie npeflBapHxejibHoro saKanbiBanna B Hero 70 % axnjiOBoro cnnpxa
(HJIH Macjia) ana HX
V. MHOPOflHblE TEJ1A HOJIOCTM HOCA
M nPMflATOHHblX HA3YX HOCA
xejia, jioKajinsyiomHeca B HOJIOCXH noca, secbMa pasnooGpasHbi
H name Bcxpenaioxca y flexefi. Hs HOJIOCXH noca oxopHHOJiapHHrojiorn y^ajiHiox
name MCJIKHC npe^Mexbi: KHMKH, MCJIKHC SycHHKH, flexajin nrpyuieK, a^pa opeXOB H T. a. OflnaKO B peflKHX cjiyqaax HHOpo^noe xejio Hoca Moacex HMexb 3H3HHxejibHbiH pasMep (CM. pnc. 18 HpHJioxceHHa). B 6ojibiiiHHCX3e cjiynaes HHOpojiHbie xejia pacnojiaraioxca B HHHCHCM HOCOBOM xo/je H, CCJIH jjo axoro HC npeflHpHHHMaJIHCb HOHblXKH HX HSBJlCHb, B nepCflHHX OXflCJiaX nOJIOCXH HOCa. B 33A-
HHX ox/iejiax Haxoaaxca HHOpo^Hbie xejia, nonasuiHe B HOC co cxoponbi HOCOFJIOXKH (nanpHMep, npn pBOxe). B npnflaxoHHbie nasyxn noca HHOpoflHbie xejia
nona/iaiox B nepByro oqepe^b npn ornecxpejibKbix paneHHax, KOJioxbix panax.
OnncaHbi cjiynan nonaaanHa HHOpojiHbix xeji B BepxHeneJiiocxHyK) nasj^cy co
ciopoHbi jiyHKH 3y6a H HS HHacnero HOcoBoro xofla icpes coycibe y JIHII, nepe-
198
Teiwa XI. HEOTJlOKHblE COCTOflHUfl B OTOPMHOnAPHHrOJlOrMM
HCCIJIHX B npOUIHOM FaHMOpOXOMHK). ITpH HSXOJKaCHHH B HOCy HCGojIblUHX
KHX HHOpojjHbix xeji Moryx oxcyxcxBOBaxb KaKHe-jiH6o HenpnaxHbie omymeHHa.
B JxajibHeHEieM, B pesyjibxaxe BbinafleHHa COUCH Kajibiina BOKpyr HHOpoflnoro
xejis oSpssyexca KaMCHb (PHHOJIHX). OcxpOKOHCHHtie HJIH Ha6yx3ioiuHe HHOpoijHbie xena (ropox, (Jmconb) Sbisaiox npHHHHOH 6ojieft B nocy, FOJIOBHOH 6onH.
HnopOAHbie xena Moryr cxaxb npHHHHOH oflHOCxopoHHero nacinopKa c rHOHHU-
V. 1/lHopoflHbie rena nonocTM Hoca n npuflaxoMHbix naayx noca
199
naxomaK, a npn noBbiineHHbix rjioxonnbix peijxneKcax — nocne nyubBe10 % pacxBopa jiH^oKaHHa, c 3xon iiejibio qejiecooGpasno ncnoJibsoBaxb
nHHuexbi, HocoBbie mnnuw FapTiviaHa.
HHOpoaHbie rejia roprami H HHSCHHX ^bixaxejibHbix nyxefi uecbMa onacHH
B CB83H C BO3MO>KHOCXbIO paSBHXHa aC(j)HKCHH. HaillC BCeFO HHOpOflHblC XCJI3 ^bl-
BJieqcHHC HHOpoflHbix xeji BCJienyio HCflonycxHMO, nocKOJibKy npHBOJjnx K H3-
xaxejibHbix nyxefi ecxpenaioxca y flexen. AcnHpaiina MarKHX npe^MexoB, naxoBO pxy /jexen, BO3Mo»Ha npn oxEJieneHKH BHHMaHHa peOenKa BO BpeMa
, nrpbi, 6era, paaroBOpa, na^enHa. V B3pocjiwx nonaflaHHio HHOpo^Hbix xeji B
flbixaxeJibHbie nyxn cnocoScxsyex CHHaceHHe saiunxHoro ropxaHHo-rnoxoHHoro
pecjwieKca, HomeuHe cteMHbix syGnbix npoxesos, ajiKorojibHoe onbaneHHe. MoMCHX acnnpauHH conpoBOHmaerca pe3KHM npncxynooGpasHbiM KanuieM, BOSHHKaex y^yiiibe, MHor^a KpaxKOBpeMCHnaa noxepa co3H3HHa. B flanbHeHiiieM OXMCq3K)xca noBxopHwe npncxynbi Kauuia, cxenoxHiecKoe ^wxaHHe.
KnuHUKa u duazHocmuKa. IlpH nonaaaHHH Kpyimoro HHOpo/jHoro xena B
ropxaHb BosHHKaex pesKoe HspymeHHC awxsHHa, ^ocxHraromee cxeneHH yayuiba,
JIHIXIHHM XpaBM3M, KpOBOXCHCHHflM H npOXajIKHBaHHK) HX B HOCOFJIOXKy, HXO CO-
CHJIbHblH KaillCJIb, HHOF/13 pBOX3. ECJIH HHOpOflHOC XCJIO (J)HKCHpOBaHO H3 ypOBHC
MH BblflCJieHHHMH, SaXpyaHCHHS HOCOBOFO flblXaHHS, KpOBOXCHCHHa H3 HOC3. ^H-
3FHO3 ycxanaBjiHBaexca npn pnHOCKonHH. HenerKO ycxaHOBHXb AHSFHOS B xex
CJiyH3aX, KOF,aa CJIHSHCXaa oGojIOHKa H36yXJI3 H KpOBOXOHHX HUH yaCC o6p33OB3-
HHCb rpanyjiaiiHH npHKpbiBaiomHe HHOpo/iHoe xejio. MexajijiHHccKHe H pp. KOHxpacxHbie HHOpoflHbie xena xopomo BbiaBJiaroxcH na R-rpaMMax, Koxopbie B ciiyH3C HCO6XO4HMOCXH BbmOJIHSIOXCH B flByx HJIH XpCX npOCKUHflX.
J\jix xoro HxoGbi yzjsjiHXb nnopoiXHoe XCJIQ H3 noca, cne/ryex npoaecxn aneCXC3HK) H 3HCMH33UHK) HOJIOCXH HOC3 C nOMOUIbK) flHKaHHa C a^peH3JIHHOM. H3-
c onacnocxbio scnnpaqKH.
HOpOflHOrO XCJI3 H3 HOC3 MOXCHO H3H3Xb C tlOIIblXKH CFO BbICM3pHJIH npOAyB3HH5I 63JIJIOHOM IlOJIHXIiep3 HCpC3 npOXHBOnOJIOMCHyK) OO-
Hoca. ECJIH xaKHM nyxeM HC yaaexca flocxHrnyxb »eji3eMoro pesyjibxsxa,
xo noKaaano HHCxpyMenxajibnoe y/ianeHHe. Opn HSBJICHCHKH HHOpoflnoro xejia y
pe6eHKa nsunenxa Heo6xoaHMO xopouio <J)HKCHpOB3Xb. Oicpyrjibie HHOpo^Hbie
xejia aoBOJibHO JICFKO HSBJieicaioxcH HsornyxbiM na KOHUC rryroBHSTbiM SOH^OM.
IIpoflOJiroBaxbie HJIH njiocKHe HHOpoflHbie xejia saxsaxbiBarox HOCOBHMH HJIH
yuiHbiMH mnrmaMH, an% yflancHHa xceJiesHbix npeflMexoa MOXCHO
MarHHXbi. PHHOJIHXH nepeflKO npnxoAHTca Apo6nxb, nocKOJibKy OHH HC
H3 nojiocxH Hoca B ero npeaflBepne. DHHBOK yaajwiox mnnuaMH.
HO B HOC saKanbmaiox 10 % p-p xjiopn^a naxpna, nnaBKH npn 3XOM
ox Mecxa CBOCFO npHKpeiuieHHa. YflaneHHe KpynHbix HHOpo^Hbix xeji (nyjin, OCKOJIKH MHH, cnapsmoB), a xaKHce HHOpo^Hbix xeji H3 OKOJiOHOcoBbix nasyx npoOH3BOAHXCH nyxeM XKHKHHOFO BCKpbixHH cooxBexcxByK)ineH nasyxH. Ilo/ixoa K
nojiocxH Hoca — nepes BepxHenejiiocxHyK) nasyxy, KaK npasHJio, npn 3XOM oaHOBpeMeHHO BCKpbiaaiox pemexHaTbiH jia6npHHX.
ronocoBOH mejiH, oxMeqaexca oxpHiuiocxb HJIH 3(J)OHHH. ITpn MCJIKHX HHOpo^Hbix
xejiax ropxsHH CXCHOS pasBHBaexca cnycxa HCKOXopoe BpeMa B pesyjibxsxe BOCnsjiHxenbHoro OXCKS CJIHSHCXOH o6o;iOHKH. V Bspocjiwx H /jexen cxapuiero BOSpacxa HHopoAHwe xejia ropxann (HFOJIKH, 6yjiaBKH, pbi6nbie KOCXH) oSnapyacHBaioxca npn nenpaMOH JiapHHrocKonHH.
B xpaxeio name nona^aiox HHopo^Hbie xejia cpeflnero pasMepa, JICFKO npoHHKaioiitHe iepe3 rojiocoByio mejn> (opeuiKH, 6b6bi, ropox, ceMena paanHHHbix pacxeHHH). XapaKxepHbiM CHMHXOMOM aBJiaexca npHcxynoo6pa3HWH Kauiejii, Koxopbin
ycHHHBaexca npn SecnoKOHHOM noBeflenHH 6ojibHoro H no noiaM. OCOOCHHO onacHW noflBnacHbie HHOpOflHbie xejia xpaxen, xapaKiepHbiM npH3HaKOM Koxopbix
exca cHMnxoM 6ajuioxHpoBaHHa, x. e. yaapa HHOpoflHoro xejia o roJiocoBbie
CXBHKH xpaxen. BapHaHXbi axoro CHMnxoMa: «xjionaHbe» npn Kaixuie, 4>opCHpoBaHHOM Bbifloxe; omymeHHe xojiHKa npn nanbnaiiHH xpaxen BO BpeMa Kaiiuia. IlpH JJMX3HHH nailHCHXa C OXKpblXbIM pXOM HHOFJJ3 CJIbllUCH CBHCXaiUHH 3ByK. IIoaBHHCHbie
CaMblMH pacnpOCXpaHCHHblMH HHOpOflHblMH XCJiaMH FJIOXKH flBJiaiOXCa MCJIKHC
HHOpo^Hbie xejia xpaxen npn Kauuie Moryr ymeMJiaxbca B ropxaHH H Bbi3bisaxb BHCsannyio accj)HKCHio. ripn nona^aHHH HHOpoaHoro xejia B 6ponx (tame B npasbiH) na6jnojjaK)Tca noBxopHbie npHcxynbi Kamna, conpoB05KjjaiomHecfl HapymeHHCM jj,bixaHHa. B npOMeacyncax MOKJjy npncxynaMH Kaiiuia 6ojn.HOH ycnoKanBaexca, ^bixaHHe
cxanoBHXca CBo6oaHbiM. B aajibHCHmeM KJiHHHKa saBHCHx ox cxeneHH napyiueHHa
pi>i6Hbie KOCXH, OCKOJIKH KocxcH H cxciuia, KycoHKH flepeBa, aepna, KOJiocbH, no-
OpOHXHOJIbHOH npOBOflHMOCXH H BOCnajIHXeJIbHblX H3MCHeHHH B JICFOHHOH XK3HH.
CXOpOHHHC EKJHOHCHHa B XJie6c (npOBOJIOKa, HFOJIKH, IUCXHHKH 3y6HbIX mCXOK,
<I>H3HKaJIbHbIMH MCXOfl3MH HCCJIBAOBaHHa H3 CXOpOHC aCnHpaUHH B SpOHX
6yjiaBKH, KpiOHKn) H x. n. KycoHKH jiaBpoBOFO jiHcxa, o6epxKH ox KOJi6acbi, xa6jiexKH Moryr (J)HKCHpOBaxi>ca y Kopna aswKa H B BaneKyjiax. OCHOBHMM CHMnxoMOM HajiHiaa HHopo^Hbix xeji B poxornoTKe asjiaexca SoJib, ocoSeHHO cnjibnaa
npn rjioxaHHH. ripncyxcxBHe HHOpOflHbix xeji ycxaHaBJiHBarox npn 4>apHHrocKOHHH. YflajieHHe HHOPOJJHOFO xejia H3 poxoBOH nacxn FJIOXKH xcejiaxejibHO npoH3-
HOFO xejia Moryr 6bixb o6napy>KeHbi ycHJieHHe FOJIOCOBOFO Apo>KaHHa,
nepKyxopnoro 3ByKa HJIH nepKyropHblH 3ByK c KOpo6oHHbiM OXTCHKOM, ocji36jieHHoe
jjbixaHHe, a xaicace cyxne H BJiaacHbie xpnnbi.
OneHb 6oJibuioe snaqeHHe B jjH3FHOcxHKe HHOpo^Hbix xeji Sponxos npHH3fljie*HX penxreHOJiorHHecKHM
Hnopo/iHbie Tejia TJIOTKH nacxo jioKajinsyioxca B poxosoH Hacxn FJIOXKH.
200
TeMa XI. HEOTDCDKHblE COCTOflHUfl B OTOPMHOnAPHHrOJIOrHH
H3JIHHHH KOHXpaCXHOFO HHOpOflHOFO TCJia OnpeACJiaexCa njIOXHM T6Hb Ha
peHTreHorpaMMe rpyzjHOH KJICTKH. HeicoHxpacxHbie HHOpOAHbie xejia B Moryx BHssaxb o6xypau,HOHHbiH axejieicras B pesyjibxaxe HOJIHOH saicynopKH 6ponxa (na R-rp
rpyAHOH KneiKH oxMenaexcfl CHHwenHe npospaHHOCxn JieroHHoro nona, BbicoKoe
croflHHe Kynojia flHa^parMbi, MexcpeSepHbie npoMexcyxKH cyaceHH, CMCmeHHe TCHH
cpeflocreHHH B cxopony nopaaceHHoro Gponxa), npn nenonHOH saicynopKe 6ponxa Ha
cxopone nopaxceHHa onpeaenaexca orpanHHCHHe HOABHXCHOCXH Kynojia AHa<f>parMbi,
CHH>KeHHe npospaiHOCTH jieroHHoro HOJIS, CMemeHne XBHH cpeflocreHHH B 6ojn>Hyio
cxopony BO BpeMa BAOxa (CHMHXOM rojibHKHexx-.flKo6coHa), B orynae KJianaHHoft
(BeHXHJibHOH) saKynopKH 6pOHxa npospannocxb jieraoro noBbiniaexca (3M(})H3eMa),
Me»cpe6epHbie npoMeacyxKH pacmnpeHbi, opranbi cpe,gocxeHHa CMemaioxcfl B SAOpocxopony, Kynoji .anaiJjparMbi Ha GojibHoft cxopone onymeH, ero 3KCKypCHH ori. BojibHbie c noflOSpeHHCM Ha HHOpoanoe xejio flbixaxejibHbix nyxen noacpOHHoii rocnHxajiroauHH. IIpH HajiHHHH cxenoaa jnoGofi cxa^HH HJIH 6ajuioxnpyiomero HHOpo/jHoro xena xpaHcnopxnpoBKa B cneuHajiHSHpOBaHHoe ox/jeneHne
BOSMOHcna xojibKO nocne Hajio>KeHHa xpaxeocxoMbi. CneuHajiHSHpOBaHHyio noMomb
3XHM 6onbHHM cjieflyex OKasbisaxb na MCCXC CHJiaMH BbiesflHOH 6pHraflbi B cocxase
Bpaneii: oxojiapHHrojiora, anecxesHOJiora H cecxpbi-aHecresHCXKH. IIpH BHesannoH
ac(J)HKCHH aGconioxHO noKasana KOHHKoxoMHa.
JiHopoflHbie xena ropxanH noflne>Kax OesoxjiaraxejitHOMy yflaneHHio. Y
Bspocjiwx HHOpoflHbie xejia o6biHHo yzjanaiox npH nenpaMOH napHHrocKonHH noa
MCCXHOH annnHKaiiHOHHOH anecxesHeH. JlexaM flJia yaaireHHa HHOpoflHHX xeji
ropxaHH HeoGxoflHMa npaMaa JiapHHrocKOHHa. Flpn HCBOSMOXCHOCXH nponsBCCXH
npaMyro JiapHHrocKonnio, CXCHOSC ropxann 3-4 cxaAHH noKasanbi cponnaa xpaxeoxoMHa HJIH KOHHKoxoMHa. HnopoflHwe xejia xpaxen, B ocoSeHHocxH 6aiuioxHpyioiHHe, nofljieacax neoxjioacHOMy y/iajieHHK). Mexo^OM BbiSopa aBJiaexca sepxnaa xpaxeo6poHxocKOHHa nojs, napKO3OM c npHMeneHneM MHOpejiaKcanxoB. Opn
H6B03MOa(HOCXH H3BJI6HI> pasGyXOICe HHOpOAHOC XCJIO HCp63 FOJIOCOByK) UJCJIb
npoH3BOAax xpaxeocxoMHio na GponxocKonHnecKOH xpy6Ke H yaanaiox HHOpoaHOC xejio nepes xpaxeocxoMy. Ilpn dpHKcnpOBanHbix HHOpo^Hbix xejiax 6ponxoB
xpeGyexca xmaxejibHoe oScneAOBanHe H noaroxoBKa 6oJibnoro K
BCpXHCH Xpaxeo6pOHXOCKOHHH C HCHOJlbSOBaHHCM MHOpCJiaKCaHXOB H
Horo GpOHXocKona Opnflejia.
OpH HeB03MO»CHOcxH yflajieHHa HHOpOAHbix xeji 6poHXOB c noMombK) xpaxeo6pOHXocKOHHH 6oJibHbie HOfljieacax nepeBOAy B oxaeJieHHe rpyAHOH xnpyprHH
(xopaKOXOMHa).
VI. HOCOBblE KPOBOTEHEHU?!
VI. HocoBbie
201
Henna 6ojiee HCM B 90 % cjiynaeB. Cpean o6mnx npHHHH nocoBbix KpoBOxeneHHH HanGojiee nacxo Bcxpe^iaioxca cjieAyiomne:
1) ocxpbie HHfjpeKHHOHHbie 3a6ojieBaHHa (name acero rpHnn);
2) apxepnanbHaa rnnepxeHSHa;
3) axepocKJiepoa;
4) 3a6ojieB3HHa cepana, HCHCHH, HOHCK B cxaAHH AeKOMnencanHH;
5) saSoJieBaHHa opranoB KpOBexBOpenHa, napynieHHa CBepxbiBaromeH CHCXCMW KPOBH, nepCAOSHpOBKH anxHKoaryjiaHxoB;
6) cenxHHCCKHe 3a6ojieBaHHa, HHXOKCHKai;HH;
7) THHO- H aBHXaMHHOSbi;
8) 6epeM6HHOCXb, BHKapnbie (ssaMCH oxcyxcxByioiuHx MeHcxpyaqng), KOHKOMexHpyromHe (conpoBoacflatomHe MencxpyauHH) KpoBOxeneHna;
9) noHHXceHHe axMoc<})epHoro aaBJieHna, 4)H3H4ecKoe nepeHanpaxceHHe, neperpeBaHHe;
10) jiynesaa 6ojiesHb.
Han6ojiee nacxtiMH MCCXHUMH npHMHHaMH HOCOBOFO KpOBOxeneHHa asjiaroxca:
1) xpasMbi Hoca, OKOJIOHOCOBHX nasyx;
2) axpo^HHCCKHe npoucccw CJIHSHCXOH o6ojiOHKH, BbisbisaiomHe JIOMKOCXB
cocyAOB, o6pa3OBaHHe KopOK — xpaBMa CJIHSHCXOH;
3) 3JiOKaiecxBeHHbie onyxojin noca H nil Hoca;
4) ao6pOKaqecxBeHHbie cocyAHCXbie onyxojin (anrHOMbi, aHrHO(J)H6poMH);
5) HHOpOAHbie xejia HOJIOCXH noca.
YcxaHOBHXb npHHHHy HocoBoro KpoBoxeneHHa cpeuy yaaexca ne sceraa. O5cjieAosaHHe 6ojn>Horo AOJMCHO 6brn> HanpaBJieHHO na 6bicxpoe peuiCHHe cjieAywmHx BOnpocoB: rae HCTOHHHK KpOBOxeneHHa, HMeiorca JIH HapyuieHHa CBepxbiBaromeH CHCXCMbl KpOBH, HC CBa33HHO JTH KpOBOXeHCHHe C KaKHM-JIHOO o6mHM 3a6ojieB3HHeM, KaKOB3
cxeneHb aneMHsaujiH, o6ycjiOBJieHHOH KpOBonoxepeH. CjieAyex HOMHHXB, HXO npn JieroHHbix, immeBOAHbix, »cenyAOlfflbix H nocxrpaBMaxHHecKHX BHyxpHHepenHbix KpoBOxeneHHax KpoBb MOHCCX BbixeKaxb H3 Hoca; H B TO ace BpeMa y xaacejibix 6onbHbix, jie»camHx na cmme, Kposb H3 Hoca nocxynaex B Hocoraoxicy, a oxxyaa nocxeneHHo sarjiaxbmaexca HJIH acnHpHpyexca H coBepmcHHO ne noKasbiBaexca B oSnacxH npeAHBepna
Hoca. B AajibHeraiieM axa KpoBb HeoaomaHHo Bbwejiaexca HSO pxa BO BpeMa Kauuia HJIH
pBoxbi. HanGojiee BaacHtiM aBJiaexca OTJiHHHe HOCOBOTO KpoBoxeHemia ox
HHa H3 HH»CHHX AbixaxeJibHbix rryxeH H acejiyoica. Flpn HOCOBOM KpoBOxeHCHHH
o6biHHO apKO KpacHoro UBexa, npn sanpOKHAbiBaraiH roJioBbi xopouio
KPOBH no saAHCH cxeffice TJIOXKH. KpoBb npH KpOBOxeneHHax HS jienotx nenHcxaa, npn
»ejiyAOHHtix KpOBOxeHCHHax — xeMHaa, CBepnyBHiaaca. HnorAa npn sarjiaxbisaHHH
KPOBH y 6ojn.Horo c HOCOBHM KpOBOxeneHHCM xaicxce HaSjnoAaexca psoxa crycxKaMH
TCMHOH KpOBH, K3K npH aCejXyAOHHOM KpOBOXCHeHHH.
HocoBbie KpOBOxeneHHa asjiaioxca CHMHXOMOM nH6o MecxHoro, jin6o o6mero 3a6ojieBaHH». O6mne 3a6ojieBaHHa asjiaioxca npH^HHoii HOCOBOFO KpOBOxe-
Han6ojiee xa»cejibiMH, yrpo»caiomHMH MCHSHH GojibHbix asjiaroxca xaK nasbiBaeMbie CHrnajibHbie HocoBbie KpoBoxeneHHa. OHH xapaKxepnsyioxca BHesanno-
!BOOH KHdgafftfedu ngdguou WOH
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K meice HJIH cocqeBHAHOMy oxpocxicy na cxopone XSMHOHSAH noca;
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ynacxKOM HexwpexyrojibHoro xpama.
VII. OCTPblE CTEHO3BI TOPTAHM
VII. OcTpbie cxeHosbi ropxam/i
205
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cxeHosoB ropxaHH aBJiaroxca socnajiHxejibHbie npoueccbi — ocxpwe CXCHOSHpyromHe JiapHHroxpaxenxbi y ^exen, OXCKH ajuiepraHecKoro H BocnajinxejibHoro
npoHCxo3Kfl6HHa, HapymeHHC KHHepssuHH (napajiHH BO3spaxHoro Hepsa), XHMHiecK3a H MexannnecKaa (B XOM HHCJIC onepaunoHHaa) xpasMa, HnopOflHbie xejia.
cxeHosbi ropxaHH BbisbiBaioxca sjioKanecxBeKHbiiviH HOBOo6pa3o(paK ropxaHH y Bspocjibix), ao6pOKanecxBeHHbiMH onyxojiaMH (nannjiropx3HH y flexeft) H HHtJieKUHOHHbiMH rpaHyjieM3MH (CKJiepOMbi, xy6epCH(})HJIHC). CxoHKHg cxeHO3bi Moryx 6bixb BpowfleHHbiMH (MeM6paHbi,
KHCXM) HJIH npHo6pexeHHbiMH (py6ubi nocjie BOcnajinxejibHbix npoueccos H onepaUHH). B 33BHCHMOCXH OX BblpSXCCHHOCXH flblXSXCJIbHOH HeAOCXaXOHHOCXH p33JIHH3IOX 4 CXaflHH CX6HO33 FOpxaHH:
1. Cx3/jHa KOMnencaiiHH npoaBJiaexca oSbinno npn (JJHSHHCCKOH narpysKe,
fljia Hee xapaKxepno ynameHne flbixaHHa sa cnex BbinaSeHna naysbilnexay B^cTXOM H BH^OXOM, yrjiy6jieHHe saoxa. ITpn SXOH cxaaHH K3KHx-jin6o 6noxHMHqeCKHX CABHrOB B OpraHH3M6 H6 HpOHCXOflHX (pH, pCO2, pO2).
2. Cxa^na nenojiHOH KOMneHcaijHH (cy6KOMneHcau,HH). H36jiK)fl3exca HHB noKoe, .zujxaHHe uiyMHoe, xapSKxepno sxaaccHHe npn
nofl3XJiHBbix~Mecx rpyflHOH KJIBXKH (na^- H noflKJiiOHHHHbix aMOK, Me»pe6epHbix npoMexcyiKOB, snHracxpna).
3. Cxs/ina aeKOMneHcauHH. O^HH H3 rjiaBHbix npHsnaKOB — rjoaBneHne
ry6, KOHHHKa HOca^jiajibaeB; pe3KO BbipsaceHajracnHpaxopHaa ogbiuiica,
Hanpa3ceTiHe~Bc"noMoraxejibHOH ^wxaxejibHOH Mycxyjiaxypbi, BosSyacflCHne. flo6ojibHoro BepXHKajibHoe. Hapa^y c SXHM oxMenaexca xaxHKapflna, no^. IIpOHCxoflHX HapymcHHe KHCJioxno-mejiOHHoro paBHOBecna (aunflO3, rnnepKanHHa, rnnoKCHa H ranoKceMHa). Bbipaacen abixaxejibHbiH iiiyM npn
Bjoxe (cxpnaop).
4. TepMHHajibHaa cxa^na (ac(J)HKCHa). flbixanne cxaHOBHXca noBepxnocxHbiM,
pasBHBaroxca naxojionwecKHe pHXMbi flbixanna (^eHH-CxoKca, KyccMayS5)71iapacxaex inraHos, nepexoaamnn B 6jie^Hocxb. Hacxynaex anaxna, najiaex AJl, nyjibc
cxanoBHxca cjia6biM, HHxeBHaHbiM. OoaBJiaexca xojiOflHHH nox, nacxynaex noxepa
COSHEHHa, 33XCM OCX3HOBKa JJblXaHHa H CepJJCHHOH fleaXCJIbHOCXH.
Heoxjioacnaa noMomb SSBHCHX ox cxa^nn cxeno33 ropxaHH H ero npHHHHbi.
He^eHHe npoBOflHxca B ycnoBHax cxaqHonapa H COCXOHX Kan HS KOHcepBaxHBHbix
MeponpnaxHH, xax H onepaxHBHbix BMemaxejibCXB.
KoHcepBaxHBHoe jieneHHe HOKSSSHO npn 1 -2-H CXS/IHH. ECJIH nssecxna npn-
Flo CKOpOCXH pa3BHXHa CXCHOSbl TOpXaHH MOryX 6bIXb MOJIHHeHOCHblMH,
4HH3 CXCH033, XO CJieflyCX CC yCXpaHHXb HJIH yMCHbUIHXb ee fleHCXBHC. OflHa H3
pasBHBaiomHMHca B xeneHHe ceKyn^ HJIH MHHyx, ocxpbiMH — B xeneHne qacoB,
raaBHbix sa^an jieneHHa — CHaxHe oxeKa ropxaHH. C sxoH uejibK) npHMeHaioxca
KopxHKOCxepOHflHbie npenapaxbi BHyxpHBCHHO, 40 % pacxBOp rjnoKO3bi, MoqeroHHbie, aHXHFHCxaMHHHbie. BnyxpHBeHHoe BBeaenHC FOPMOHOB CHHMSCX OXCK
ropxaHH OHCHb 6bicxpo, B csasn c HCM sxy MaHHnyjiaunio nasBajiH «BHyxpHBCHHaa xpaxeoxoMHa».
flHCH, XpOHHHeCKHMH - B XCHCHHe HCaCJIb, MBCaijeB H JICX, CXOHKHMH - H6
HMeiOILtHMH flHHaMHKH.
MojiHHeHOCHbie cxenosbi ropxann BbistiBaioxca KpynnbiMH HHOpoflHHMH xeHJIH MexanHHCCKOH xpaBMOH c paspymeHHein xpameBoro ocxosa ropxaHH,
206
Teiua XI. HEOTJ1O)KHblE COCTOflHHfl B OTOPHHOJIAPHHrOJIOfMH
npHHnna cxenosa — jiapnnrocnasM. LJeJiecoo6pa3HO npHMenenHe
HOBOKaHHOBbix 6:ioKafl (BHyxpHHOcoaaa), aHXHcnacxHnecKHe cpezicxBa
Tpexba npHHHHa cxenoaa — CKomreHne B jjbrxaxejibHbrx nyxax BSSKOH CJIHSH,
MOKpoxbi, sacbrxarorueH B KOPKH. ^jia pasMarneHHa CJIHSH HasHaiaroTca <J)epMCHxbi (jiH^asa, xHMOxpHncHH), 4 % 6nicap6oHax naxpna.
XHpypraiecKoe jreneHHe norcaaano npn 3-4-H eraAHax cxenosa. TpaxeocxoMHa asjiaexca 3KcxpeHHbiM xHpyprHnecKHM BMeuraxejibcxBOM, npeflnpHHHMaeMMM fljia cnacenna JKHSHH 6o:ibHoro. Ona 3(}><}>eKXHBHa npH 3-fi cxaflHH cxenosa,
a6cojiK)XHO noKasana npn 4-H cxaanH cxenosa ropxaHH. TpaxeocxoMHH MOMCCX
6wxb npe/inpHHaxa K&K npcxjmnaKXHHecKaa onepaiiHfl npn 2-H cxa^HH cxenosa
npoi})HJiaKXHKH BHesanHoro yayuiba y GcwibHbix paKOM ropxaHH (npeseHXHBxpaxeociOMHa).
CoBpeMCHHbie noKaaaHHa K TpaxeocxoMHH ynnxbiBarox (J)opMy naxo^orHH
H ocHOBHyro uenb xpaxeocxoMHH M Moryr 6wxb pasAejienbi Ha cuerpynnbi:
I rpynna. HenpoxoflHMOCxb flbixaxenbHoro xpaKxa B sepxHCM oxflene, Kor^a
xpaxeocxoMHa npHMewaexca fljw npo(J)HJiaKXHKH MexaHHHecKOH ac4)HKCHH, x. e. no
noKasaHKaM. HenpoxoflHMOCxb awxaxejibnoro xpaxxa B BepxHCM
MTOKBX 6bixb oGycjioBJiena sanynopKOH ropxaHH, H3MeHeHHeM ee CTCHOK
(OXCK, onyxojib), caaBJiCHHCM HSBHC, napanHHOM nepBHO-MHiueHHoro annapaxa.
II rpynna. HapymeHHe npoxo^HMOCTH abixaxejibHOro xpaxxa
ceicpeuHH HJIH acnnpaiiHH. E[ejib xpaxeocxoMHH — apeHHpoBaHHe
nyxeii c noMombio Kaxexepa HJIH sneKxpooxcoca. Tanaa cnxyaiiHa cos/taexca npn
acnnpauHH pBOXHbix Mace, KpoBH, CKonneHHH npoayKxoB ceKpeiiHH, oxeice nerKHX.
III rpynna. HapymeHHe GnoMexaHHKH flbixaxejibnoro axxa B coHexaHHH c
OKKJIKDSHCH xpaxeo6poHXHajibHoro aepeaa. Ilo/io6Hoe cocxoaHHe Ha6juo4aexca
npH MHOXCCXBCHHOM nepenoMC pe6ep, nocjie xopaKanbHbix onepauHH H x. a.
TpaxeocxoMna c;iy>KHX jyix yMeHbmeHHa «BpeAHoro» npocxpancxBa, a xaicace ana
ApeHHpOBaHHa flbixaxeJibHtix nyxeH.
IV rpynna. ITaxojiorHa flbixanna na (j)OHe CBo6oAHbix awxaxejibHbix nyxen.
TaKoe cocxoanne o6ycnoBneHO ueHxpanbHbiM nopaMceHHCM atixaHHa — napypnxMa (awxaHHe xnna Heim-CxoKca, Bnoxa) npH CHHJKCHHH oGteivia JieBCHXHJiauHH, pasBHXHH rHnepKanHHH H rnnoKceMHH. IJejiL xpaxeocxoMHH — yMCHbiueHHe «BpeflHoro» npocxpancxBa.
V rpynna. Ocxpaa ne/rpcxaxoHnocxb HJIH oxcyxcxBHe .nuxaHHH — paasuBaexca npH yrnexenHH abixanHa 6ap6nxypaxaMH, KOKaHHOM, npn yxonneHHH, yffyuieHHH, nopaaceHHH SJICKXPHHCCKHM XOKOM, nojrHOMneJiHxe, MHacxeHHH. Llejrb
TpaxeocxoMHH — noflKJiioHeHHe annapaxos HCKyccTBeHHoro flbixanna (HBJI).
Bee nepeHHCJienHbre rpynnbi noKasaHHH ana xpaxeocxoMHH aBJiaroxca ycJIOBHHMH, sxa onepai[Ha HensSeHCHa, CCJIH HHxySaqHa ropxaHH H xpaxen nescj)(J)eKXHBHa HJIH npoxHBonoKasaHa.
VII. OcTpbieCTeHO3biropraHM
207
Cireayex pa3JiHnaxb xepMHHbr «xpaxeocxoMHa» H <opaxeoxoMHa». B nepBOM
cjiynae na xpaxero HaKnaabrsaexca CXOHKOC coycxbe c BHemneH cpejJioH («stoma» —
pox), BO BXOPOM cjiynae HMeexca B BH«y BpeMCHHoe pacceqeHne xpaxen na
BbrnojrHeHHa KaKOH-jrHSo MaHHny.rwu.HH c nocjieayromHM yrirHBaHHCM nefyeKia.
OcoBeHHOCTH rpaxeocTOMHH y aereii. /I,exaM name npHMenaexca
xpaxeocxoMHa, Hxo6br nsSeacaxb BO3MO»Horo nepnxoH/ipHxa ropxaHH, npojie»cH6H. B nocjieayiomeM MOXCCX pasBHXbca py6noBHH CXCHOS ropxann H xpaxen. B
AexcKOM BO3pacxe xpaxeocxoMHa cjioacnee BCJreacxBHe ocoSbrx anaxoMO-xonorpa(})HHecKHX oco6eHHOCxeir ropxaHH H xpaxen (pwxjraa KJiexnaxKa B noflCKJiaAOHHOM oxaejie, UIHPOKHH nepemeeK mnxoBHanoH TKCJICSW, najrHnne BHJTOHKOBOH
, BucxoaHHe Kynojra njreBpbr). TpaxeocxoMHro y j^exeii uejiecoo6pa3HO
nocjie npe^BapHxejibHOH HHxy6auHH; cjieayex H36eraxb npHMeneHna ocxpbrx xpaxeoxoMHnecKHX KPIOHKOB.
YnpomeHHi>ie BHJJM ropjioceneHHH. Ilpn 4-n cxa^HH cxenosa ropxann, KOr^a nex ycjroBHH H speMCHH jura BbrnonneHHsi XKHKHHOH xpaxeocxoMHH, npn
BHesanHOH ocxanoBKe AtixaHHa cjre/iyex npoHSBecxn KOHHKOXOMHK) HJTH KpHKOKOHHKOXOMHK). B03MO)KHbre OCJIOaCHCHHa ynpOmeHHHX BHflOB rOpJIOCeHCHHa
nepHXOHapnx, npojiexcHH CJIHSHCXOH o6o;roHKH xpaxen c nocjreayiomHM py6n,oBWM CXCHO3OM.
Bonpocbi A/in MToroeoro KOHxponn 3H3HMM no rewe XI
1. Ho K3KMM npuHunnaM npOBOflnxca HXO pan o6nacxn /inqa?
2. flO K3KMM npM3H3KaM MO>KHO BblflBHTb H33aribHyK» /IMKBOpeiO?
3. KaKne cocxonHnq xpeGyror oxcpoHHTb npoeeAeHne penosmjHM KOCTeii Hoca?
4. KaKOBbl npMHMHbl BO3HMKHOBeHMfl HOCOBOPO
5. KaKHe cymecxeyiox cnoco6bi ociaHOBKM HOCOBOFO
6. KaKne cymecrByiox npaenna yflaneHkin MHOpoflHbix xen yxa, Hoca?
7. KaK MSMeHflercfi KnunnKa CTenosa ropxaHM B aaBMCMwocxn or craflMM?
8. FlO K3KMM nOK33aHHflM npOBOflflT TpaXeOCTOMMK)?
9. Karae KOHcepsaTMBHoe JieseHwe npoaoflHTcn 6onbHbiM co II cxacxeHosa ropraHM?
10. KaKUM o6pa3ow nposoflnx yflaneHne MHOpoflHbix Ten us HM>KHMX
ixarejibHbiM nyxefi?
11. B H6M oxjiMMne rpaxeocTOMMM or rpaxeoTOMMM?